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Li SX, Cheung FTW, Chan NY, Chan JWY, Zhang J, Li AM, Espie CA, Gradisar M, Wing YK. Effects of cognitive behavioural therapy and bright light therapy for insomnia in youths with eveningness: study protocol for a randomised controlled trial. Trials 2024; 25:246. [PMID: 38594725 PMCID: PMC11005158 DOI: 10.1186/s13063-024-08090-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Insomnia and eveningness are common and often comorbid conditions in youths. While cognitive behavioural therapy for insomnia (CBT-I) has been suggested as a promising intervention, it remains unclear whether it is sufficient to also address circadian issues in youths. In addition, despite that light has been shown to be effective in phase-shifting one's circadian rhythm, there has been limited data on the effects of bright light therapy and its combination with CBT-I on sleep and circadian outcomes in youths. The current protocol outlines a randomised controlled trial that examines the efficacy of CBT-I and CBT-I plus bright light therapy (BLT) in reducing insomnia severity, improving mood symptoms and daytime functioning (e.g. sleepiness, fatigue, cognitive function), and improving subjective and objective sleep and circadian measures compared to a waitlist control group. METHODS We will carry out a randomised controlled trial (RCT) with 150 youths aged 12-24 who meet the criteria of insomnia and eveningness. Participants will be randomised into one of three groups: CBT-I with bright light therapy, CBT-I with placebo light, and waitlist control. Six sessions of CBT-I will be delivered in a group format, while participants will be currently asked to use a portable light device for 30 min daily immediately after awakening throughout the intervention period for bright light therapy. The CBT-I with light therapy group will receive bright constant green light (506 lx) while the CBT-I with placebo light group will receive the modified light device with the LEDs emitting less than 10 lx. All participants will be assessed at baseline and post-treatment, while the two active treatment groups will be additionally followed up at 1 month and 6 months post-intervention. The primary outcome will be insomnia severity, as measured by the Insomnia Severity Index. Secondary outcomes include self-reported mood, circadian, daytime functioning, and quality of life measures, as well as sleep parameters derived from actigraphy and sleep diary and neurocognitive assessments. Objective measures of the circadian phase using dim-light melatonin onset assessment and sleep parameters using polysomnography will also be included as the secondary outcomes. DISCUSSION This study will be the first RCT to directly compare the effects of CBT-I and BLT in youths with insomnia and eveningness. Findings from the study will provide evidence to inform the clinical management of insomnia problems and eveningness in youths. TRIAL REGISTRATION ClinicalTrials.gov NCT04256915. Registered on 5 February 2020.
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Affiliation(s)
- Shirley Xin Li
- Department of Psychology, Sleep Research Clinic and Laboratory, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China.
| | - Forrest Tin Wai Cheung
- Department of Psychology, Sleep Research Clinic and Laboratory, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Ngan Yin Chan
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Joey Wing Yan Chan
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jihui Zhang
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Center for Sleep and Circadian Medicine, The Affiliated Brain Hospital of Guangzhou Medicine University, Guangzhou, Guangdong, China
| | - Albert Martin Li
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Colin A Espie
- Nuffield Department of Clinical Neurosciences and Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, UK
| | - Michael Gradisar
- WINK Sleep Pty Ltd, Adelaide, Australia
- Sleep Cycle AB, Gothenburg, Sweden
| | - Yun-Kwok Wing
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Wu HS, Gao F, Davis JE, Given CW. Effects of chronotype-tailored bright light intervention on post-treatment symptoms and quality of life in breast cancer survivors. Support Care Cancer 2023; 31:705. [PMID: 37975923 DOI: 10.1007/s00520-023-08157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Bright light therapy holds promise for reducing common symptoms, e.g., fatigue, experienced by individuals with cancer. This study aimed to examine the effects of a chronotype-tailored bright light intervention on sleep disturbance, fatigue, depressive mood, cognitive dysfunction, and quality of life among post-treatment breast cancer survivors. METHODS In this two-group randomized controlled trial (NCT03304587), participants were randomized to receive 30-min daily bright blue-green light (12,000 lx) or dim red light (5 lx) either between 19:00 and 20:00 h or within 30 min of waking in the morning. Self-reported outcomes and in-lab overnight polysomnography sleep study were assessed before (pre-test) and after the 14-day light intervention (post-test). RESULTS The sample included 30 women 1-3 years post-completion of chemotherapy and/or radiation for stage I to III breast cancer (mean age = 52.5 ± 8.4 years). There were no significant between-group differences in any of the symptoms or quality of life (all p > 0.05). However, within each group, self-reported sleep disturbance, fatigue, depressive mood, cognitive dysfunction, and quality of life-related functioning showed significant improvements over time (all p < 0.05); the extent of improvement for fatigue and depressive mood was clinically relevant. Polysomnography sleep findings showed that a number of awakenings significantly decreased (p = 0.011) among participants who received bright light, while stage 2 sleep significantly increased (p = 0.015) among participants who received dim-red light. CONCLUSION The findings support using light therapy to manage post-treatment symptoms in breast cancer survivors. The unexpected symptom improvements among dim-red light controls remain unexplained and require further investigation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03304587, October 19, 2017.
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Affiliation(s)
- Horng-Shiuann Wu
- Michigan State University College of Nursing, C347 Bott Building, 1355 Bogue Street, East Lansing, MI, 48824, USA.
| | - Feng Gao
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Jean E Davis
- University of South Carolina College of Nursing, Columbia, SC, USA
| | - Charles W Given
- Michigan State University College of Nursing, C347 Bott Building, 1355 Bogue Street, East Lansing, MI, 48824, USA
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Chakrabarti S, Jolly AJ, Singh P, Yadhav N. Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder. World J Psychiatry 2023; 13:495-510. [PMID: 37701540 PMCID: PMC10494771 DOI: 10.5498/wjp.v13.i8.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023] Open
Abstract
Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, Chandigarh UT, India
| | - Amal J Jolly
- Department of Psychiatry, Black Country Healthcare NHS Foundation Trust, Dudley DY2 8PS, West Midlands, United Kingdom
| | - Pranshu Singh
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India
| | - Nidhi Yadhav
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, Chandigarh UT, India
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Futenma K, Takaesu Y, Komada Y, Shimura A, Okajima I, Matsui K, Tanioka K, Inoue Y. Delayed sleep-wake phase disorder and its related sleep behaviors in the young generation. Front Psychiatry 2023; 14:1174719. [PMID: 37275982 PMCID: PMC10235460 DOI: 10.3389/fpsyt.2023.1174719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023] Open
Abstract
Delayed sleep-wake phase disorder (DSWPD) is a sleep disorder in which the habitual sleep-wake timing is delayed, resulting in difficulty in falling asleep and waking up at the desired time. Patients with DSWPD frequently experience fatigue, impaired concentration, sleep deprivation during weekdays, and problems of absenteeism, which may be further complicated by depressive symptoms. DSWPD is typically prevalent during adolescence and young adulthood. Although there are no studies comparing internationally, the prevalence of DSWPD is estimated to be approximately 3% with little racial differences between Caucasians and Asians. The presence of this disorder is associated with various physiological, genetic and psychological as well as behavioral factors. Furthermore, social factors are also involved in the mechanism of DSWPD. Recently, delayed sleep phase and prolonged sleep duration in the young generation have been reported during the period of COVID-19 pandemic-related behavioral restrictions. This phenomenon raises a concern about the risk of a mismatch between their sleep-wake phase and social life that may lead to the development of DSWPD after the removal of these restrictions. Although the typical feature of DSWPD is a delay in circadian rhythms, individuals with DSWPD without having misalignment of objectively measured circadian rhythm markers account for approximately 40% of the cases, wherein the psychological and behavioral characteristics of young people, such as truancy and academic or social troubles, are largely involved in the mechanism of this disorder. Recent studies have shown that DSWPD is frequently comorbid with psychiatric disorders, particularly mood and neurodevelopmental disorders, both of which have a bidirectional association with the pathophysiology of DSWPD. Additionally, patients with DSWPD have a strong tendency toward neuroticism and anxiety, which may result in the aggravation of insomnia symptoms. Therefore, future studies should address the effectiveness of cognitive-behavioral approaches in addition to chronobiological approaches in the treatment of DSWPD.
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Affiliation(s)
- Kunihiro Futenma
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
| | - Yoko Komada
- Institute for Liberal Arts, Tokyo Institute of Technology, Tokyo, Japan
| | - Akiyoshi Shimura
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
- Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Isa Okajima
- Department of Psychological Counseling, Faculty of Humanities, Tokyo Kasei University, Tokyo, Japan
| | - Kentaro Matsui
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
- Department of Clinical Laboratory, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Kosuke Tanioka
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Inoue
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
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Xu M, Lu S, Liu J, Xu F. Effectiveness of horticultural therapy in aged people with depression: A systematic review and meta-analysis. Front Public Health 2023; 11:1142456. [PMID: 36969640 PMCID: PMC10031070 DOI: 10.3389/fpubh.2023.1142456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/09/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundDepression, an increasing global crisis, has affected many people's daily life, especially for older adults. Horticultural therapy has been widely used in non-pharmacological treatment for patients with depression, with a body of studies demonstrating its therapeutic effects. However, a lack of systematic reviews and meta-analyses makes it difficult to get a holistic picture of this research field.ObjectivesWe aimed to evaluate the reliability of the previous studies and the effectiveness of horticultural therapy (including the intervention of environmental settings, activities, and duration) on older adults with depression.MethodsThis systematic review was conducted under the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) guidelines. We searched relevant studies in multiple databases, and the original search was finished on 25 September 2022. We included studies using randomized controlled trials (RCTs) or quasi-experimental designs.ResultsWe yielded a total of 7,366 studies and finally included 13 which involved 698 aged people with depression. Results from meta-analysis indicated significant effects of horticultural therapy on reducing depressive symptoms for the older adults. Besides, we found different outcomes among various horticultural interventions (such as environmental setting, activities, and duration). Depression reduction was more effective in care-providing settings than in community settings; participatory activities were more effective in reducing depression than observational activities; intervention of 4–8 weeks might represent the optimal course of treatment compared to interventions more than 8 weeks in duration.ConclusionWe came up with a comprehensive set of recommendations based on the meta-analysis: aged people in care-providing settings with depression could get the most benefit from horticultural therapy by participating in participatory activities for 4–8 weeks.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022363134, identifier CRD42022363134.
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Affiliation(s)
- Meijing Xu
- College of Horticulture, China Agricultural University, Beijing, China
| | - Shan Lu
- College of Horticulture, China Agricultural University, Beijing, China
| | - Jianjiao Liu
- Faculty of Architecture, Building and Planning, University of Melbourne, Melbourne, VIC, Australia
| | - Feng Xu
- College of Horticulture, China Agricultural University, Beijing, China
- *Correspondence: Feng Xu
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Tang JH, Wing YK, Chan JWY, Lo RSK. Bright Light Therapy for Cancer-related Fatigue in a Palliative Care Unit: A Feasibility Study. J Pain Symptom Manage 2023; 65:e237-e240. [PMID: 36441072 DOI: 10.1016/j.jpainsymman.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/29/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Yun Kwok Wing
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR
| | - Joey W Y Chan
- Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR.
| | - Raymond S K Lo
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR.
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Spitschan M, Santhi N, Ahluwalia A, Fischer D, Hunt L, Karp N, Lévi F, Pineda-Torra I, Vidafar P, White R. Science Forum: Sex differences and sex bias in human circadian and sleep physiology research. eLife 2022; 11:65419. [PMID: 35179486 PMCID: PMC8963875 DOI: 10.7554/elife.65419] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Growing evidence shows that sex differences impact many facets of human biology. Here we review and discuss the impact of sex on human circadian and sleep physiology, and we uncover a data gap in the field investigating the non-visual effects of light in humans. A virtual workshop on the biomedical implications of sex differences in sleep and circadian physiology then led to the following imperatives for future research: (1) design research to be inclusive and accessible, (2) implement recruitment strategies that lead to a sex-balanced sample, (3) use data visualization to grasp the effect of sex, (4) implement statistical analyses that include sex as a factor and/or perform group analyses by sex, where possible, (5) make participant-level data open and available to facilitate future meta-analytic efforts.
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Affiliation(s)
| | - Nayantara Santhi
- Department of Psychology, Northumbria University, Newcastle, United Kingdom
| | - Amrita Ahluwalia
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Dorothee Fischer
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany
| | | | - Natasha Karp
- Data Sciences and Quantitative Biology, AstraZeneca, Hinxton, United Kingdom
| | - Francis Lévi
- Warwick Medical School, University of Warwick, Warwick, United Kingdom
| | - Ines Pineda-Torra
- Centre for Cardiometabolic and Vascular Science, University College London, London, United Kingdom
| | - Parisa Vidafar
- Department of Psychiatry, University of Michigan, Ann Arbor, United States
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Golubova TF, Nuvoli AV. [Effect of iodine-bromine baths on stress-systems indicators in children with autism spectrum disorders]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOI FIZICHESKOI KULTURY 2022; 99:42-49. [PMID: 35236065 DOI: 10.17116/kurort20229901142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
UNLABELLED The continuous increase in the prevalence of autism spectrum disorders (ASD) in the population, the debatable nature of many aspects of etiology, pathogenesis, and treatment of these disorders justify the urgent need for the development of effective medical rehabilitation methods affecting the pathogenetic mechanisms.Exposure of children with ASD to external stimuli in excessive force often leads to the stress-systems response not corresponding to the compensation abilities of the body. OBJECTIVE To evaluate the effect of iodine-bromine baths on stress-system indicators in children with ASD. MATERIAL AND METHODS The study involved 74 children with ASD (F84) aged 3 to 14 years (mean age 6.23±0.37 years) included in the main group (MG). The control group (CG) consisted of 25 healthy children.The examination included detailed history taking, examination by specialists, assessment of disease severity using CARS scale, evaluation of β-endorphin, adrenocorticotropic hormone (ACTH), and cortisol levels in blood serum by ELISA. Thirty-four (45.9%) children had a moderate autism level (total score 30-37), and 40 (54.1%) children had severe autism (total score 37-60). In the MG, there were 27 (36.5%) children with mild symptoms of hyperactivity (subgroup A) and 47 (63.5%) children with severe aggression, tantrums, and increased hyperactivity (subgroup B). All MG patients were assigned into two subgroups by randomization: Subgroup 1: 30 children with ASD received health resort treatment (HRT) without iodine-bromine baths (IB); Subgroup 2: 44 children with ASD received similar HRT and IB. RESULTS Statistically significant increase of β-endorphin, ACTH and cortisol levels (p<0.01, p<0.05, p<0.01, respectively) in children with ASD (compared to those in CG children) was identified. In children without hyperactivity, a moderate increase of these parameters was noted; significantly higher values were observed in children with severe hyperactivity, impulsiveness, and aggression (p<0.05, p<0.001, respectively). After treatment, there was a statistically significant increase in β-endorphin level in subgroup 1 children who received HRT without IB, while in children of subgroups A and B (p<0.05, p<0.05, p<0.01, respectively), there was a decrease in ACTH level (p<0.05, p<0.01, p<0.001 respectively) and a trend towards a cortisol level decrease. Inclusion of IB in HRT course associated with a significant decrease of β-endorphin level in children of subgroups A and B (p<0.001), a decrease of ACTH level (p<0.001) and cortisol (p<0.001, p<0.01, p<0.001, respectively), which resulted in vicious circle breaking and normalization of relations between stress-limiting and stress-releasing parts of pathogenesis. CONCLUSION Most children with autism spectrum disorders showed significant increases in β-endorphin, adrenocorticotropic hormone, and cortisol levels, indicating dysfunction between the stress-limiting and stress-releasing systems, as well as between the central and peripheral parts of the stress-releasing chain. The tonic effect of resort treatment was noted, limiting its use in children with autism spectrum disorders, increased hyperactivity, and aggression. The inclusion of iodine-bromine baths in resort treatment has a calming non-medicinal effect and can be recommended for use in children with symptoms of severe hyperactivity.
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Affiliation(s)
- T F Golubova
- Research Institute of Children's Resorts, Physiotherapy and Medical Rehabilitation, Yevpatoria, Russia
| | - A V Nuvoli
- Research Institute of Children's Resorts, Physiotherapy and Medical Rehabilitation, Yevpatoria, Russia
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Goncharova N, Chigarova O, Oganyan T. Age-related and individual features of the HPA axis stress responsiveness under constant light in nonhuman primates. Front Endocrinol (Lausanne) 2022; 13:1051882. [PMID: 36699023 PMCID: PMC9870316 DOI: 10.3389/fendo.2022.1051882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is a key adaptive neuroendocrine system, dysfunction of which plays an important role in the increasing incidence of stress-dependent age-related pathology. Among the environmental factors effecting increase age-related diseases, great importance is given to disturbances of the light-dark schedule, particularly with increased illumination at night. While disruption of the light-dark schedule has long been recognized as a powerful behavioral stressor, little is known regarding stress reactivity of the HPA under constant light (CL) conditions, especially with aging and depending on the features of stress behavior. The purpose of this investigation was to study the age-related and individual features of the HPA axis response to acute stress exposure (ASE) under chronic CL in nonhuman primates that are known to differ in behavioral responsiveness to stress. Young and old female rhesus monkeys (with control standard behavior or anxiety and depression-like behavior) were exposed to CL (24 h light/day, 330-400 lux for 4 to 8 weeks). Control young and old monkeys were exposed to standard lighting (SL) with natural light during the day and darkness at night. All animals were subjected to ASE (restriction of mobility for 2 hours), functional tests with corticotrophin-releasing hormone and arginine-vasopressin, and study of circadian rhythms of cortisol and pineal melatonin secretion. For the first time an inhibitory effect of CL on the reaction of the adrenal cortex to ASE was revealed in all individuals, regardless of age and preexisting behavior stress reactivity, the mechanisms of which were age-dependent: due to inhibition of the pituitary ACTH secretion in young animals and mainly not affecting the ACTH secretion in old individuals. There were no significant changes in melatonin secretion both in young and old animals. The observed CL inhibition of adrenal cortical reactivity to ASE may be useful to correct increased vulnerability to ASE observed in individuals with preexisting anxiety and depression-like stress behaviors. On the other hand, the CL induced decrease in adrenal stress reactivity of behaviorally normal animals suggests a potential risk of reducing the adaptive capacity of the organism under conditions of continuous light exposure.
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Son J, Shin J. Bimodal effects of sunlight on major depressive disorder. Compr Psychiatry 2021; 108:152232. [PMID: 33905989 DOI: 10.1016/j.comppsych.2021.152232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/10/2021] [Accepted: 02/12/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Seasonal patterns in the effect of sunlight on depression, where depression decreases when sunlight increases, have been observed in previous studies. In this study, we demonstrate a bimodal effect of sunlight on depression - short-term increases in sunlight increase depression and long-term increases in sunlight decrease depression. The analysis showed that the significant effect of sunlight is temporary and appears only when seasonal changes are severe within a given year. METHODS We analyzed approximately 530,000 cases where patients visited hospital for depression in Korea from January 1 to December 31, 2016. We measured the daily average amount of sunlight and daily sunlight for the 30 days previous to the day of measurement using data from 96 weather stations. To analyze the effect of sunlight, several climatic variables and local dummies were added to the negative binomial model, and the period in which the effect of sunlight was significant was derived as a term of the interaction between the month variable and sunlight. RESULTS When the average effects of climatic factors such as temperature, precipitation, and humidity were removed, the number of cases of depression increased when the daily average amount of sunlight increased [IRR = 1.024 (95% CI: 1.009 to 1.039)]; this effect was significant only in January and May. The number of cases of depression decreased with higher daily average sunlight for the previous 30 days increasing [IRR = 0.917 (95% CI: 0.892 to 0.944)], and this effect was significant only in January, March, and May. CONCLUSIONS The effect of sunlight on depression appears in both the short and long terms, but the effect is significant only for limited periods. The data examined in this study supports a pattern where short-term daily sunlight increases depression and daily sunlight for the previous 30 days decreases depression.
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Affiliation(s)
- Jungmin Son
- College of Economics and Management, Chungnam National University, 99 Daehak-ro, Yuseong-gu, Daejeon 34134, Republic of Korea.
| | - Jinhee Shin
- College of Economics and Management, Chungnam National University, 99 Daehak-ro, Yuseong-gu, Daejeon 34134, Republic of Korea.
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Trinh A, Jain P, Sabahath S, Wang D, Megna JL, Leontieva L. Feasibility of Adjunctive Bright Light Therapy for Depressive Symptoms on an Acute Psychiatric Floor. Cureus 2021; 13:e13945. [PMID: 33747665 PMCID: PMC7968349 DOI: 10.7759/cureus.13945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Bright light therapy (BLT) has been increasingly used as an experimental treatment in non-seasonal unipolar depression. While clinical trials have demonstrated the efficacy of BLT in ameliorating depression for outpatients, studies examining BLT in the psychiatric inpatient setting are currently lacking. AIM The purpose of this study is to explore whether BLT as adjunctive treatment for depressive symptoms on an acute psychiatric floor is feasible and explore associated changes in depressive symptoms. METHODS An observational, cross-sectional study was conducted at State University of New York (SUNY) Upstate 4B acute inpatient psychiatric unit. BLT was administered to participating patients as adjunctive therapy to their psychopharmacological and psychotherapy treatments on a daily basis throughout their hospitalization. Beck Depression Inventory-II (BDI-II), Hamilton Rating Scale for Depression (HAM-D), and Outcome Questionnaire-45.2 (OQ-45.2) were administered before commencing BLT and after their last BLT session. Changes to the aforementioned measures before and after BLT treatment, the dose response of measure changes based on number of sessions, and the hospital length of stay along with the secondary factors such as age, gender, other psychiatric comorbidities, social factors, and psychiatric medications were analyzed. RESULTS BLT is feasible on acute psychiatric inpatient floor with adherence of 94% and has very few side effects. The repeated measures of depression and functioning demonstrated significant decrease in depression and improvement in functioning. Although not statistically significant, clinical meaningful dose-response relationship was found between a number of BLT sessions and improvement in depressive symptoms with five BLT sessions being an optimal amount for depression amelioration. CONCLUSION BLT combined with the ongoing psychopharmacological treatment was well tolerated and easy to administer. It offers a simple, safe, and cost-effective approach to augmenting depressive treatment on an acute psychiatric floor.
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Affiliation(s)
- Alisa Trinh
- Psychiatry, State University of New York Upstate Medical University, Syracuse, USA
| | - Pratik Jain
- Psychiatry, State University of New York Upstate Medical University, Syracuse, USA
| | - Shaikh Sabahath
- Psychiatry, State University of New York Upstate Medical University, Syracuse, USA
| | - Dongliang Wang
- Public Health and Preventive Medicine, State University of New York Upstate Medical University, Syracuse, USA
| | - James L Megna
- Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse, USA
| | - Luba Leontieva
- Psychiatry, State University of New York Upstate Medical University, Syracuse, USA
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12
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"Shedding Light on Light": A Review on the Effects on Mental Health of Exposure to Optical Radiation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041670. [PMID: 33572423 PMCID: PMC7916252 DOI: 10.3390/ijerph18041670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/11/2021] [Accepted: 02/03/2021] [Indexed: 01/10/2023]
Abstract
In relation to human health and functioning, light, or more specifically optical radiation, plays many roles, beyond allowing vision. These may be summarized as: regulation of circadian rhythms; consequences of direct exposure to the skin; and more indirect effects on well-being and functioning, also related to lifestyle and contact with natural and urban environments. Impact on mental health is relevant for any of these specifications and supports a clinical use of this knowledge for the treatment of psychiatric conditions, such as depression or anxiety, somatic symptom disorder, and others, with reference to light therapy in particular. The scope of this narrative review is to provide a summary of recent findings and evidence on the regulating functions of light on human beings’ biology, with a specific focus on mental health, its prevention and care.
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Trkulja V, Barić H. Current Research on Complementary and Alternative Medicine (CAM) in the Treatment of Major Depressive Disorder: An Evidence-Based Review. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1305:375-427. [PMID: 33834410 DOI: 10.1007/978-981-33-6044-0_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Complementary and alternative medicine (CAM) encompasses a wide range of different non-mainstream therapies that have been increasingly used for treatment or adjunctive treatment of various ailments with mood disorders and "depressive difficulties" being two of the commonly CAM (self-)medicated conditions. We focus specifically on clinically diagnosed (in line with the standard criteria) depressive disorders, primarily major depressive disorder (MDD), and overview evidence of efficacy/safety of a range of CAM modalities addressing exclusively randomized controlled trials (RCTs) and systematic reviews/meta-analyses of RCTs. The list of addressed CAM interventions is not exhaustive: due to space limitation, addressed are interventions with at least a few conducted RCTs in the specific clinical conditions. We try to provide numerical and meaningful data as much as it is possible and to (a) indicate situations in which the reported data/estimates might have been "too enthusiastic" and (b) warn about heterogeneity of results that, together with other possible limitations (various biases and imprecision), results in uncertainty about the effects.
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Affiliation(s)
- Vladimir Trkulja
- Department of Pharmacology, Zagreb University School of Medicine, Zagreb, Croatia.
| | - Hrvoje Barić
- Department of Neurosurgery, University Hospital Center Zagreb, Zagreb, Croatia
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Siemann JK, Grueter BA, McMahon DG. Rhythms, Reward, and Blues: Consequences of Circadian Photoperiod on Affective and Reward Circuit Function. Neuroscience 2020; 457:220-234. [PMID: 33385488 DOI: 10.1016/j.neuroscience.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 02/01/2023]
Abstract
Circadian disruptions, along with altered affective and reward states, are commonly associated with psychiatric disorders. In addition to genetics, the enduring influence of environmental factors in programming neural networks is of increased interest in assessing the underpinnings of mental health. The duration of daylight or photoperiod is known to impact both the serotonin and dopamine systems, which are implicated in mood and reward-based disorders. This review first examines the effects of circadian disruption and photoperiod in the serotonin system in both human and preclinical studies. We next highlight how brain regions crucial for the serotoninergic system (i.e., dorsal raphe nucleus; DRN), and dopaminergic (i.e., nucleus accumbens; NAc and ventral tegmental area; VTA) system are intertwined in overlapping circuitry, and play influential roles in the pathology of mood and reward-based disorders. We then focus on human and animal studies that demonstrate the impact of circadian factors on the dopaminergic system. Lastly, we discuss how environmental factors such as circadian photoperiod can impact the neural circuits that are responsible for regulating affective and reward states, offering novel insights into the biological mechanisms underlying the pathophysiology, systems, and therapeutic treatments necessary for mood and reward-based disorders.
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Affiliation(s)
- Justin K Siemann
- Department of Biological Sciences, Vanderbilt University, Nashville, TN 37235, USA; Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, TN 37235, USA
| | - Brad A Grueter
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37235, USA; Department of Anesthesiology, Vanderbilt University, Nashville, TN 37235, USA; Vanderbilt Center for Addiction Research, Vanderbilt University, Nashville, TN 37235, USA; Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, TN 37235, USA
| | - Douglas G McMahon
- Department of Biological Sciences, Vanderbilt University, Nashville, TN 37235, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN 37235, USA; Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, TN 37235, USA.
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Aguilar-Latorre A, Navarro C, Oliván-Blázquez B, Gervilla E, Magallón Botaya R, Calafat-Villalonga C, García-Toro M, Boira S, Serrano-Ripoll MJ. Effectiveness and cost-effectiveness of a lifestyle modification programme in the prevention and treatment of subclinical, mild and moderate depression in primary care: a randomised clinical trial protocol. BMJ Open 2020; 10:e038457. [PMID: 33372070 PMCID: PMC7772323 DOI: 10.1136/bmjopen-2020-038457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 10/19/2020] [Accepted: 11/19/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Major depression is a highly prevalent pathology that is currently the second most common cause of disease-induced disability in our society. The onset and continuation of depression may be related to a wide variety of biological and psychosocial factors, many of which are linked to different lifestyle aspects. Therefore, health systems must design and implement health promotion and lifestyle modification programmes (LMPs), taking into account personal factors and facilitators. The main objective of this protocol is to analyse the clinical effectiveness, cost-effectiveness and cost utility of an LMP and an LMP with information and communication technologies (ICTs) as adjunctive treatment for depression in primary care patients. The secondary objectives are to analyse the clinical effectiveness in the subgroup that presents comorbidity and to analyse the correlation between personal factors on health behaviour and lifestyle patterns. METHODS AND ANALYSIS A randomised, multicenter pragmatic clinical trial with three parallel groups consisting of primary healthcare patients suffering from subclinical, mild or moderate depression. The following interventions will be used: (1) Usual antidepressant treatment with psychological advice and/or psychotropic drugs prescribed by the general practitioner (treatment as usual (TAU)). (2) TAU+LMP. A programme to be imparted in six weekly 90-minute group sessions, intended to improve the following aspects: behavioural activation+daily physical activity+adherence to the Mediterranean diet pattern+sleep hygiene+careful exposure to sunlight. (3) TAU+LMP+ICTs: healthy lifestyle recommendations (TAU+LMP)+monitoring using ICTs (a wearable smartwatch). The primary outcome will be the depressive symptomatology and the secondary outcomes will be the quality of life, the use of health and social resources, personal factors on health behaviour, social support, lifestyle patterns and chronic comorbid pathology. Data will be collected before and after the intervention, with 6-month and 12-month follow-ups. ETHICS AND DISSEMINATION This study has been approved by the Clinical Research Ethics Committee of Aragón (approval number: C.P.-C.I. PI18/286) and the Research Ethics Committee of the Balearic Islands (IB3950/19 PI). Data distribution will be anonymous. Results will be disseminated via conferences and papers published in peer-reviewed, open-access journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03951350).
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Affiliation(s)
- Alejandra Aguilar-Latorre
- Primary Health Care Research Group of Aragón (GAIAP), Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
| | - Capilla Navarro
- Department of Psychology, University of the Balearic Islands, Palma de Mallorca, Spain
| | - Bárbara Oliván-Blázquez
- Primary Health Care Research Group of Aragón (GAIAP), Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
- Department of Psychology and Sociology, University of Zaragoza, Zaragoza, Spain
| | - Elena Gervilla
- Department of Psychology, University of the Balearic Islands, Palma de Mallorca, Spain
- Statistic and psychometric procedures implemented in Health Sciences Research Group, Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
| | - Rosa Magallón Botaya
- Primary Health Care Research Group of Aragón (GAIAP), Institute for Health Research Aragón (IIS Aragón), Zaragoza, Spain
- Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Zaragoza, Spain
| | | | - Mauro García-Toro
- Mental disorders of high prevalence Research Group (TRAMAP), Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
- Department of Medicine, University of the Balearic Islands, Palma de Mallorca, Spain
| | - Santiago Boira
- Department of Psychology and Sociology, University of Zaragoza, Zaragoza, Spain
| | - María Jesús Serrano-Ripoll
- Department of Psychology, University of the Balearic Islands, Palma de Mallorca, Spain
- Research in Preventive Activities and Promotion and in Cancer Illes Balears (GRAPP-CAIB), Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
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16
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Razumov AN, Ezhov VV, Dovgan IA, Ponomarenko GN. [Therapeutic effects of climototherapy: scientomatrical analysis of evidence-based studies]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2020; 97:59-67. [PMID: 33307664 DOI: 10.17116/kurort20209706159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Scientometrical analysis of studies the use of climatotherapy methods and formulation of guidelines based on the evidence obtained during the analysis. MATERIAL AND METHODS The article presents the data of scientometrical analysis of 40 publications on the use of climatotherapy in spa practice. RESULTS Clinical effects and proposed mechanisms of action of the proven efficacy climatotherapy methods - aerotherapy, heliotherapy and thalassotherapy for the patients with various chronic diseases are presented. The clinical directions for the using of climatotherapy methods in climatic resorts are highlighted. CONCLUSIONS Regular generalization and analysis of existing evidence-based studies is required, as well as the implementation of new high-quality randomized controlled clinical trials to study the effects of climate therapy on a wide range of patients with common socially significant diseases.
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Affiliation(s)
- A N Razumov
- Moscow Center for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine, Moscow, Russia
| | - V V Ezhov
- Academic scientific-research Institute of physical treatment methods, medical climatology and rehabilitation named after I.M. Sechenov, Yalta, Russia
| | - I A Dovgan
- Saki Central Military Clinical Sanatorium named after N.I. Pirogov of the Ministry of Defense of the Russian Federation, Saki, Russia
| | - G N Ponomarenko
- Federal Scientific Center of Rehabilitation of the Disabled named after G.A. Albrecht, Saint Petersburg, Russia.,North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
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17
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Bais B, Kamperman AM, Bijma HH, Hoogendijk WJ, Souman JL, Knijff E, Lambregtse-van den Berg MP. Effects of bright light therapy for depression during pregnancy: a randomised, double-blind controlled trial. BMJ Open 2020; 10:e038030. [PMID: 33115894 PMCID: PMC7594358 DOI: 10.1136/bmjopen-2020-038030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Approximately 11%-13% of pregnant women suffer from depression. Bright light therapy (BLT) is a promising treatment, combining direct availability, sufficient efficacy, low costs and high safety for both mother and child. Here, we examined the effects of BLT on depression during pregnancy. DESIGN Randomised, double-blind controlled trial. SETTING Primary and secondary care in The Netherlands, from November 2016 to March 2019. PARTICIPANTS 67 pregnant women (12-32 weeks gestational age) with a DSM-5 diagnosis of depressive disorder (Diagnostic and Statistical Manual of Mental Disorders). INTERVENTIONS Participants were randomly allocated to treatment with either BLT (9000 lux, 5000 K) or dim red light therapy (DRLT, 100 lux, 2700 K), which is considered placebo. For 6 weeks, both groups were treated daily at home for 30 min on awakening. Follow-up took place weekly during the intervention, after 6 weeks of therapy, 3 and 10 weeks after treatment and 2 months postpartum. PRIMARY AND SECONDARY OUTCOME MEASURES Depressive symptoms were measured primarily with the Structured Interview Guide for the Hamilton Depression Scale-Seasonal Affective Disorder. Secondary measures were the Hamilton Rating Scale for Depression and the Edinburgh Postnatal Depression Scale. Changes in rating scale scores of these questionnaires over time were analysed using generalised linear mixed models. RESULTS Median depression scores decreased by 40.6%-53.1% in the BLT group and by 50.9%-66.7% in the DRLT group. We found no statistically significant difference in symptom change scores between BLT and DRLT. Sensitivity and post-hoc analyses did not change our findings. CONCLUSIONS Depressive symptoms of pregnant women with depression improved in both treatment arms. More research is necessary to determine whether these responses represent true treatment effects, non-specific treatment responses, placebo effects or a combination hereof. TRIAL REGISTRATION NUMBER NTR5476.
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Affiliation(s)
- Babette Bais
- Psychiatry, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Astrid M Kamperman
- Psychiatry, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Hilmar H Bijma
- Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Witte Jg Hoogendijk
- Psychiatry, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Jan L Souman
- Lighting Applications, Signify NV, Eindhoven, Noord-Brabant, The Netherlands
| | - Esther Knijff
- Psychiatry, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Mijke P Lambregtse-van den Berg
- Psychiatry, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
- Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
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Lee HP, Gaharwar AK. Light-Responsive Inorganic Biomaterials for Biomedical Applications. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 7:2000863. [PMID: 32995121 PMCID: PMC7507067 DOI: 10.1002/advs.202000863] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/24/2020] [Indexed: 05/19/2023]
Abstract
Light-responsive inorganic biomaterials are an emerging class of materials used for developing noninvasive, noncontact, precise, and controllable medical devices in a wide range of biomedical applications, including photothermal therapy, photodynamic therapy, drug delivery, and regenerative medicine. Herein, a range of biomaterials is discussed, including carbon-based nanomaterials, gold nanoparticles, graphite carbon nitride, transition metal dichalcogenides, and up-conversion nanoparticles that are used in the design of light-responsive medical devices. The importance of these light-responsive biomaterials is explored to design light-guided nanovehicle, modulate cellular behavior, as well as regulate extracellular microenvironments. Additionally, future perspectives on the clinical use of light-responsive biomaterials are highlighted.
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Affiliation(s)
- Hung Pang Lee
- Biomedical EngineeringCollege of EngineeringTexas A&M UniversityCollege StationTX77843USA
| | - Akhilesh K. Gaharwar
- Biomedical EngineeringCollege of EngineeringTexas A&M UniversityCollege StationTX77843USA
- Material Science and EngineeringCollege of EngineeringTexas A&M UniversityCollege StationTX77843USA
- Center for Remote Health Technologies and SystemsTexas A&M UniversityCollege StationTX77843USA
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19
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Pilkington K, Wieland LS. Self-care for anxiety and depression: a comparison of evidence from Cochrane reviews and practice to inform decision-making and priority-setting. BMC Complement Med Ther 2020; 20:247. [PMID: 32778171 PMCID: PMC7418416 DOI: 10.1186/s12906-020-03038-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-care refers to a range of activities and approaches undertaken by an individual to maintain health and manage ill-health which may include various complementary or alternative approaches. The purpose of this study was to identify the self-care approaches used by the general public for depression and anxiety, assess the usefulness of Cochrane reviews for informing decisions on self-care and highlight any gaps in the evidence. METHODS Searches were carried out for surveys of self-care for anxiety and/or depression and for Cochrane reviews and protocols of interventions with potential for use in self-care. Data was extracted from each review and Plain Language Summaries assessed for content, consistency and readability. Interventions reported in surveys and in Cochrane reviews were compared and effectiveness of each assessed. RESULTS Surveys from 10 countries reported a variety of self-care interventions, 17 of which appeared in 2 or more surveys and which included dietary supplements, herbal medicines, mind-body therapies and various forms of exercise. Twenty-two reviews and 5 protocols on potential self-care interventions were identified, the majority in depression. Twelve interventions were judged effective or promising, most with small effect sizes. Readability of summaries was highly variable: half were written at college/university level. Several commonly used approaches were not covered by Cochrane reviews. CONCLUSIONS This study has revealed the interventions currently used by the general public which are judged effective or promising based on Cochrane reviews. Some disparity is highlighted between interventions used in practice and the availability of reliable evidence, and in the presentation of effectiveness and safety. Being able to direct patients to reliable, accessible information is a positive step in ensuring effective patient-centered, evidence-informed care. Addressing gaps, ensuring consistency and increasing usability of evidence intended for the general public will support this goal.
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Affiliation(s)
- Karen Pilkington
- School of Health and Care Professions, University of Portsmouth, James Watson West, 2 King Richard 1st Road, Portsmouth, P01 2FR, UK.
| | - Lisa Susan Wieland
- Center for Integrative Medicine, University of Maryland School of Medicine, 520 West Lombard Street, East Hall, Baltimore, MD, 21201, USA
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20
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Hamers PCM, Festen DAM, Bindels PJE, Hermans H. The effect of bright light therapy on depressive symptoms in adults with intellectual disabilities: Results of a multicentre randomized controlled trial. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2020; 33:1428-1439. [PMID: 32583931 PMCID: PMC7687277 DOI: 10.1111/jar.12770] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 04/09/2020] [Accepted: 05/22/2020] [Indexed: 01/01/2023]
Abstract
Background Although a large number of adults with intellectual disabilities have depressive symptoms, non‐pharmacological treatments are scarce. The present authors investigated whether bright light therapy (BLT) is effective in decreasing depressive symptoms compared to care as usual. Methods This multicentre randomized controlled trial consisted of three study groups (10,000 lux BLT, dim light BLT and a no‐BLT group). Participants received BLT for 30 min in the morning (14 consecutive days), additional to their regular care. Primary outcome was as follows: depressive symptoms measured with the ADAMS Depressive Mood subscale 1 week after the end of BLT (same time period in the no‐BLT group). Results Forty‐one participants were included in our trial. In both BLT groups, a significant decrease in depressive symptoms was seen. No significant differences were found between 10,000 lux BLT and no‐BLT (p = .199) and no significant differences between dim light BLT and no‐BLT (p = .451). A minimum amount of side effects and no adverse events were reported. Conclusions In both BLT interventions, a decrease in depressive symptoms was seen. With 10,000 lux BLT, depressive symptoms decreased even below the clinical cut‐off point, which makes BLT a promising intervention for clinical practice.
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Affiliation(s)
- Pauline C M Hamers
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Amarant, Healthcare Organization for People with Intellectual disabilities, Tilburg, The Netherlands
| | - Dederieke A M Festen
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Ipse de Bruggen, Healthcare Organization for People with Intellectual Disabilities, Zoetermeer, The Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heidi Hermans
- Department of General Practice, Intellectual Disability Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Amarant, Healthcare Organization for People with Intellectual disabilities, Tilburg, The Netherlands
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21
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van Hout LJE, Rops LEP, Simons CJP. Treating winter depressive episodes in bipolar disorder: an open trial of light therapy. Int J Bipolar Disord 2020; 8:17. [PMID: 32476072 PMCID: PMC7261710 DOI: 10.1186/s40345-020-00182-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/06/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Light therapy has been used to treat winter depression in bipolar disorder, although the dose, duration, and timing of treatment have differed. The present study is an open trial of light therapy for depressive episodes in autumn/winter using a Dutch protocol specific for patients with a bipolar disorder. METHODS Data were collected for the seasons September-April 2017-2018 and September-April 2018-2019. In total, 58 patients received light therapy for a minimum of 7 days and a maximum of 21 days; there was a follow-up measurement after two weeks. Outcomes were quick inventory of depressive symptomatology (QIDS) scores and side effects. RESULTS QIDS scores were significantly lower at the last day of therapy (B = - 6.00, p < 0.001) and 2 weeks after the end of treatment (B = - 6.55, p < 0.001) compared with pre-intervention. Remission (QIDS ≤ 5) was reached in 55% of the treatments and response (50% symptom reduction) in 57% of the treatments. Side effects were mild; two hypomanic periods occurred. CONCLUSIONS The Dutch light therapy protocol for patients with a bipolar disorder may be effective in treating a seasonal depression and side effects are mild. Light therapy deserves a prominent place in the treatment because effects may be large and quick.
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Affiliation(s)
- Lotte J E van Hout
- GGzE, Institute for Mental Health Care Eindhoven, Dr. Poletlaan 40, 5626 ND, Eindhoven, The Netherlands.
| | - Lisette E P Rops
- GGzE, Institute for Mental Health Care Eindhoven, Dr. Poletlaan 40, 5626 ND, Eindhoven, The Netherlands
| | - Claudia J P Simons
- GGzE, Institute for Mental Health Care Eindhoven, Dr. Poletlaan 40, 5626 ND, Eindhoven, The Netherlands
- Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
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Bright light therapy in the treatment of patients with bipolar disorder: A systematic review and meta-analysis. PLoS One 2020; 15:e0232798. [PMID: 32437356 PMCID: PMC7241702 DOI: 10.1371/journal.pone.0232798] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/21/2020] [Indexed: 01/10/2023] Open
Abstract
The treatment of depressive symptoms of bipolar disorder (BD) has received increasing attention. Recently, some studies have shown that bright light therapy (BLT) seems to be useful for BD depression. This meta-analysis is intended to further elucidate the role of BLT in depressive symptoms in patients with BD. Register of Systematic Reviews PROSPERO: CRD 420191 33642.Randomized controlled trials and cohort studies were retrieved in PubMed, Cochrane Library, EMbase, Web of Science, CINHAL, CBM, CNKI, VIP, and Wanfang from their foundation to March 2020, and other sources as supplement was also retrieved. Data were extracted after strict evaluation of literature quality by two researchers, and Meta-analysis was conducted on literatures that met the inclusion criteria. Meta-analysis was performed using Revman 5.3 software. In total, 12 studies including 847 patients with BD depression were included in our meta-analysis. A meta-analysis found significant differences between BLT and placebo for the following outcomes: (1) depression severity before and after BLT [SMD = -0.43, 95% CI (-0.73,-0.13), P<0.05] in RCT and [SMD = -2.12, 95% CI (-2.3,-1.94), P<0.05] in cohort studies.; (2) the efficacy of duration/timing of light therapy for depressive symptoms in BD [I2 = 85%, SMD = -1.88, 95% CI (-2.04, -1.71),P<0.05] and [I2 = 71%, SMD = -2.1,95% CI(-2.24, -1.96), P<0.05]; (3) the efficacy of different color/color temperatures for depressive symptoms in BD [I2 = 0%, SMD = -0.56, 95% CI (-0.92, -0.19), P<0.05] and [I2 = 97%, SMD = -1.74, 95% CI (-1.99, -1.49), P<0.05].We performed a subgroup meta-analysis of studies that used different light intensities. The results showed that light intensity≥5000 lux significantly reduced the severity of depression. And patients without psychotropic drugs revealed significantly decreased disease severity [I2 = 0%, SMD = -0.6, 95% CI (-1.06,-0.13), P<0.05]. Limitations of the study include studies only assessed short-term effects, and insufficient duration may underestimate adverse reactions and efficacy. Our results highlight the significant efficiency of BLT in the treatment of bipolar depression. Prospective studies with more rigorous design and consistent follow-up.
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Takeshima M, Utsumi T, Aoki Y, Wang Z, Suzuki M, Okajima I, Watanabe N, Watanabe K, Takaesu Y. Efficacy and safety of bright light therapy for manic and depressive symptoms in patients with bipolar disorder: A systematic review and meta-analysis. Psychiatry Clin Neurosci 2020; 74:247-256. [PMID: 31917880 PMCID: PMC7187384 DOI: 10.1111/pcn.12976] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 11/30/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023]
Abstract
AIM This systematic review and meta-analysis evaluated whether bright light therapy (BLT) is an effective and safe treatment for manic/depressive symptoms and a preventive measure for recurrent mood episodes in patients with bipolar disorder. METHODS A literature search of major electronic databases was conducted in June 2019, including all published articles up to that date. Two researchers independently selected relevant publications, extracted data, and evaluated methodological quality according to the Cochrane criteria. RESULTS Six randomized controlled trials (RCT) evaluated the efficacy of BLT for bipolar depression. A meta-analysis found no significant differences between BLT and placebo for the following outcomes: (i) rates of remission from depressive episodes (risk ratio [RR]: 1.81, 95% confidence interval [CI]: 0.43 to 7.64, P = 0.42); (ii) depressive symptom scores (standardized mean difference: -0.25, 95%CI: -0.74 to 0.23, P = 0.30); and (iii) rates of manic switching (RR: 1.00, 95%CI: 0.28 to 3.59, P = 0.26). The sensitivity analysis for studies with low overall indirectness did show a significant antidepressant effect for BLT (RR: 3.09, 95%CI: 1.62 to 5.90, P = 0.006). No RCT investigated the effect of BLT in preventing the recurrence of mood episodes in the euthymic state or in improving manic symptoms in the manic state. No severe adverse events were reported. CONCLUSION While a meta-analysis was unable to demonstrate the efficacy of BLT for bipolar depression, a sensitivity analysis did show a significant effect. Further well-designed studies are needed to clarify the effectiveness of BLT, not only for the depressive state but also for other states, in the treatment of bipolar disorder.
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Affiliation(s)
- Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Tomohiro Utsumi
- Department of Psychiatry, Jikei University School of Medicine, Tokyo, Japan
| | - Yumi Aoki
- Psychiatric & Mental Health Nursing, St. Luke's International University, Tokyo, Japan
| | - Zhe Wang
- Renaissance School of Medicine at Stony Brook University, New York, USA
| | - Masahiro Suzuki
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Isa Okajima
- Department of Psychological Counseling, Faculty of Humanities, Tokyo Kasei University, Tokyo, Japan
| | - Norio Watanabe
- Department of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
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Eisenberg MJ, Habib B, Alcaraz M, Thombs BD, Filion KB. Bright light therapy for depressive symptoms in hospitalized cardiac patients: A randomized controlled pilot trial. PLoS One 2020; 15:e0230839. [PMID: 32226019 PMCID: PMC7105123 DOI: 10.1371/journal.pone.0230839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 03/09/2020] [Indexed: 11/18/2022] Open
Abstract
Depression is common among cardiac patients and associated with adverse cardiovascular outcomes. Bright light therapy has emerged as a promising treatment for depressive symptoms, however it has not yet been investigated in this population. We conducted a double-blind, randomized, placebo-controlled pilot trial to assess the feasibility of a larger-scale trial testing bright light therapy for depressive symptoms in cardiac patients. Patients hospitalized for an acute coronary syndrome or undergoing cardiac surgery were randomized to either bright light (10,000 lux) or dim light placebo (500 lux) lamps for 30 minutes each day over 4 weeks, beginning in-hospital. Depression was quantified using the Patient Health Questionnaire 9 (PHQ-9) and Depression Anxiety and Stress Scales (DASS-21). The Short-Form Health Survey 36 (SF-36) was used to measure quality of life. A total of 175 patients were screened and 15 were randomized (8 treatment, 7 placebo) (8.6%) over 10 months. Despite protocol amendments which broadened the inclusion criteria, the trial was terminated early for infeasibility based on the rate of enrollment (1–2 participants/month), with 39.5% of the target sample (38 participants) enrolled. Future trials should take into account the timing of the onset of depressive symptoms in these patients, and consider a less conservative approach to eligibility as well as ways to increase the acceptability of bright light therapy in hospitalized cardiac patients. Once enrolled, our findings suggest that most participants will adhere to the assigned treatment and complete follow-up.
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Affiliation(s)
- Mark J. Eisenberg
- Center for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Division of Cardiology, Jewish General Hospital/McGill University, Montreal, QC, Canada
- * E-mail:
| | - Bettina Habib
- Center for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, QC, Canada
| | - Maria Alcaraz
- Center for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, QC, Canada
| | - Brett D. Thombs
- Center for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada
| | - Kristian B. Filion
- Center for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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Volf C, Aggestrup AS, Petersen PM, Dam-Hansen C, Knorr U, Petersen EE, Engstrøm J, Jakobsen JC, Hansen TS, Madsen HØ, Hageman I, Martiny K. Dynamic LED-light versus static LED-light for depressed inpatients: study protocol for a randomised clinical study. BMJ Open 2020; 10:e032233. [PMID: 31988225 PMCID: PMC7045110 DOI: 10.1136/bmjopen-2019-032233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/19/2019] [Accepted: 01/07/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Retrospective studies conducted in psychiatric inpatient wards have shown a relation between the intensity of daylight in patient rooms and the length of stay, pointing to an antidepressant effect of ambient lighting conditions. Light therapy has shown a promising antidepressant effect when administered from a light box. The emergence of light-emitting diode (LED) technology has made it possible to build luminaires into rooms and to dynamically mimic the spectral and temporal distribution of daylight. The objective of this study is to investigate the antidepressant efficacy of a newly developed dynamic LED-lighting system installed in an inpatient ward. METHODS AND ANALYSIS In all, 150 inpatients with a major depressive episode, as part of either a major depressive disorder or as part of a bipolar disorder, will be included. The design is a two-arm 1:1 randomised study with a dynamic LED-lighting arm and a static LED-lighting arm, both as add-on to usual treatment in an inpatient psychiatric ward. The primary outcome is the baseline adjusted score on the 6-item Hamilton Depression Rating Scale at week 3. The secondary outcomes are the mean score on the Suicidal Ideation Attributes Scale at week 3, the mean score on the 17-item Hamilton Depression Rating Scale at week 3 and the mean score on the World Health Organisation Quality of Life-BREF (WHOQOL-BREF) at week 3. The spectral distribution of daylight and LED-light, with a specific focus on light mediated through the intrinsically photosensitive retinal ganglion cells, will be measured. Use of light luminaires will be logged. Assessors of Hamilton Depression Rating Scale scores and data analysts will be blinded for treatment allocation. The study was initiated in May 2019 and will end in December 2021. ETHICS AND DISSEMINATION No ethical issues are expected. Results will be published in peer-reviewed journals, disseminated electronically and in print and presented at symposia. TRIAL REGISTRATION NUMBER NCT03821506; Pre-results.
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Affiliation(s)
- Carlo Volf
- Psychiatric Centre Copenhagen, University Hospital Copenhagen, Copenhagen, Denmark
| | - Anne Sofie Aggestrup
- Psychiatric Centre Copenhagen, University Hospital Copenhagen, Copenhagen, Denmark
| | - Paul Michael Petersen
- Department of Photonics Engineering, Technical University of Denmark, Lyngby, Denmark
| | - Carsten Dam-Hansen
- Department of Photonics Engineering, Technical University of Denmark, Lyngby, Denmark
| | - Ulla Knorr
- Psychiatric Centre Copenhagen, University Hospital Copenhagen, Copenhagen, Denmark
| | - Ema Erkocevic Petersen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Engstrøm
- Centre for Clinical Intervention Research, Rigshospitalet, Kobenhavn, Denmark
| | - Janus C Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Ida Hageman
- Mental Health Services in the Capital Region of Denmark, Kobenhavn O, Denmark
| | - Klaus Martiny
- Psychiatric Centre Copenhagen, University Hospital Copenhagen, Copenhagen, Denmark
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Haller H, Anheyer D, Cramer H, Dobos G. Complementary therapies for clinical depression: an overview of systematic reviews. BMJ Open 2019; 9:e028527. [PMID: 31383703 PMCID: PMC6686993 DOI: 10.1136/bmjopen-2018-028527] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES As clinical practice guidelines vary widely in their search strategies and recommendations of complementary and alternative medicine (CAM) for depression, this overview aimed at systematically summarising the level 1 evidence on CAM for patients with a clinical diagnosis of depression. METHODS PubMed, PsycInfo and Central were searched for meta-analyses of randomised controlled clinical trials (RCTs) until 30 June 2018. Outcomes included depression severity, response, remission, relapse and adverse events. The quality of evidence was assessed according to Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considering the methodological quality of the RCTs and meta-analyses, inconsistency, indirectness, imprecision of the evidence and the potential risk of publication bias. RESULTS The literature search revealed 26 meta-analyses conducted between 2002 and 2018 on 1-49 RCTs in major, minor and seasonal depression. In patients with mild to moderate major depression, moderate quality evidence suggested the efficacy of St. John's wort towards placebo and its comparative effectiveness towards standard antidepressants for the treatment for depression severity and response rates, while St. John's wort caused significant less adverse events. In patients with recurrent major depression, moderate quality evidence showed that mindfulness-based cognitive therapy was superior to standard antidepressant drug treatment for the prevention of depression relapse. Other CAM evidence was considered as having low or very low quality. CONCLUSIONS The effects of all but two CAM treatments found in studies on clinical depressed patients based on low to very low quality of evidence. The evidence has to be downgraded mostly due to avoidable methodological flaws of both the original RCTs and meta-analyses not following the Consolidated Standards of Reporting Trials and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Further research is needed.
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Affiliation(s)
- Heidemarie Haller
- Department of Internal and Integrative Medicine, Evang. Kliniken Essen-Mitte, Faculty of Medicine, Universitat Duisburg-Essen, Essen, Germany
| | - Dennis Anheyer
- Department of Internal and Integrative Medicine, Evang. Kliniken Essen-Mitte, Faculty of Medicine, Universitat Duisburg-Essen, Essen, Germany
| | - Holger Cramer
- Department of Internal and Integrative Medicine, Evang. Kliniken Essen-Mitte, Faculty of Medicine, Universitat Duisburg-Essen, Essen, Germany
| | - Gustav Dobos
- Department of Internal and Integrative Medicine, Evang. Kliniken Essen-Mitte, Faculty of Medicine, Universitat Duisburg-Essen, Essen, Germany
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Desautels C, Savard J, Ivers H. Moderators of Cognitive Therapy and Bright Light Therapy Effects on Depressive Symptoms in Patients with Breast Cancer. Int J Behav Med 2019; 26:380-390. [PMID: 31264101 DOI: 10.1007/s12529-019-09802-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cognitive therapy (CT) and bright light therapy (BLT) have been found to be effective to treat depressive symptoms in breast cancer patients. No study has investigated the baseline patients' characteristics that are associated with better outcomes with CT vs. BLT in this population. This study aimed to assess, in breast cancer patients, the moderating role of eight clinical variables on the effects of CT and BLT on depressive symptoms. METHODS This is a secondary analysis of a randomized controlled trial conducted in 59 women who received an 8-week CT or BLT and completed questionnaires evaluating depression and possible moderating variables. RESULTS Patients benefited more from BLT when they had no prior history of major depressive disorder, higher depression scores on the Hospital Anxiety and Depression Scale (HADS-D) at baseline, a greater initial preference for BLT, and when they received BLT during spring or summer. Patients benefited more from CT when they had a lower initial preference for receiving CT, higher depression scores on the HADS-D, and seasonal depressive symptoms. CONCLUSIONS Although replication is needed, findings of this study suggest the existence of different profiles of patients more likely to benefit from CT and BLT. TRIAL REGISTRATION NCT01637103 https://clinicaltrials.gov/ct2/show/NCT01637103.
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Affiliation(s)
- Caroline Desautels
- School of Psychology, Université Laval, Québec, QC, Canada
- CHU de Québec - Université Laval Research Center, Québec, QC, Canada
- Université Laval Cancer Research Center, Québec, QC, Canada
| | - Josée Savard
- School of Psychology, Université Laval, Québec, QC, Canada.
- CHU de Québec - Université Laval Research Center, Québec, QC, Canada.
- Université Laval Cancer Research Center, Québec, QC, Canada.
- Centre de recherche du CHU de Québec - L'Hôtel-Dieu de Québec, 11 Côte du Palais, Québec, Québec, G1R 2J6, Canada.
| | - Hans Ivers
- School of Psychology, Université Laval, Québec, QC, Canada
- CHU de Québec - Université Laval Research Center, Québec, QC, Canada
- Université Laval Cancer Research Center, Québec, QC, Canada
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Yan L, Lonstein JS, Nunez AA. Light as a modulator of emotion and cognition: Lessons learned from studying a diurnal rodent. Horm Behav 2019; 111:78-86. [PMID: 30244030 PMCID: PMC6456444 DOI: 10.1016/j.yhbeh.2018.09.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 08/13/2018] [Accepted: 09/17/2018] [Indexed: 01/03/2023]
Abstract
Light profoundly affects the behavior and physiology of almost all animals, including humans. One such effect in humans is that the level of illumination during the day positively contributes to affective well-being and cognitive function. However, the neural mechanisms underlying the effects of daytime light intensity on affect and cognition are poorly understood. One barrier for progress in this area is that almost all laboratory animal models studied are nocturnal. There are substantial differences in how light affects nocturnal and diurnal species, e.g., light induces sleep in nocturnal mammals but wakefulness in diurnal ones, like humans. Therefore, the mechanisms through which light modulates affect and cognition must differ between the chronotypes. To further understand the neural pathways mediating how ambient light modulates affect and cognition, our recent work has developed a diurnal rodent model, the Nile grass rat (Arvicanthis niloticus), in which daytime light intensity is chronically manipulated in grass rats housed under the same 12:12 hour light/dark cycle. This simulates lighting conditions during summer-like bright sunny days vs. winter-like dim cloudy days. Our work has revealed that chronic dim daylight intensity results in higher depression- and anxiety-like behaviors, as well as impaired spatial learning and memory. Furthermore, we have found that hypothalamic orexin is a mediator of these effects. A better understanding of how changes in daytime light intensity impinge upon the neural substrates involved in affect and cognition will lead to novel preventive and therapeutic strategies for seasonal affective disorder, as well as for non-seasonal emotional or cognitive impairments associated with light deficiency.
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Affiliation(s)
- Lily Yan
- Department of Psychology & Neuroscience Program, Michigan State University, East Lansing, MI 48824, USA.
| | - Joseph S Lonstein
- Department of Psychology & Neuroscience Program, Michigan State University, East Lansing, MI 48824, USA
| | - Antonio A Nunez
- Department of Psychology & Neuroscience Program, Michigan State University, East Lansing, MI 48824, USA
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29
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Rutten S, Vriend C, Smit JH, Berendse HW, van Someren EJW, Hoogendoorn AW, Twisk JWR, van der Werf YD, van den Heuvel OA. Bright light therapy for depression in Parkinson disease: A randomized controlled trial. Neurology 2019; 92:e1145-e1156. [PMID: 30770426 DOI: 10.1212/wnl.0000000000007090] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 11/05/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the efficacy of bright light therapy (BLT) in reducing depressive symptoms in patients with Parkinson disease (PD) and major depressive disorder (MDD) compared to a control light. METHODS In this double-blind controlled trial, we randomized patients with PD and MDD to treatment with BLT (±10,000 lux) or a control light (±200 lux). Participants were treated for 3 months, followed by a 6-month naturalistic follow-up. The primary outcome of the study was the Hamilton Depression Rating Scale (HDRS) score. Secondary outcomes were objective and subjective sleep measures and salivary melatonin and cortisol concentrations. Assessments were repeated halfway, at the end of treatment, and 1, 3, and 6 months after treatment. Data were analyzed with a linear mixed-model analysis. RESULTS We enrolled 83 participants. HDRS scores decreased in both groups without a significant between-group difference at the end of treatment. Subjective sleep quality improved in both groups, with a larger improvement in the BLT group (B [SE] = 0.32 [0.16], p = 0.04). Total salivary cortisol secretion decreased in the BLT group, while it increased in the control group (B [SE] = -8.11 [3.93], p = 0.04). CONCLUSION BLT was not more effective in reducing depressive symptoms than a control light. Mood and subjective sleep improved in both groups. BLT was more effective in improving subjective sleep quality than control light, possibly through a BLT-induced decrease in cortisol levels. CLINICALTRIALSGOV IDENTIFIER NCT01604876. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that BLT is not superior to a control light device in reducing depressive symptoms in patients with PD with MDD.
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Affiliation(s)
- Sonja Rutten
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands.
| | - Chris Vriend
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Jan H Smit
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Henk W Berendse
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Eus J W van Someren
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Adriaan W Hoogendoorn
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Jos W R Twisk
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Ysbrand D van der Werf
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Odile A van den Heuvel
- From Amsterdam UMC (S.R., C.V., J.H.S., E.J.W.v.S., A.W.H., O.A.v.d.H.), Vrije Universiteit Amsterdam, Department of Psychiatry, Amsterdam Neuroscience; Department of Research and Innovation (S.R., J.H.S., A.W.H., O.A.v.d.H.), GGZ InGeest; Amsterdam UMC (C.V., H.W.B., Y.D.v.d.W.), Vrije Universiteit Amsterdam, Department of Anatomy and Neurosciences, Amsterdam Neuroscience; Amsterdam UMC (H.W.B.), Vrije Universiteit Amsterdam, Department of Neurology, Amsterdam Neuroscience; Department of Sleep and Cognition (E.J.W.v.S., Y.D.v.d.W.), Netherlands Institute for Neuroscience; Department of Integrative Neurophysiology (E.J.W.v.S.), Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, VU University; and Amsterdam UMC (J.W.T.), Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
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Hurd D, Herrera M, Brant JM, Coombs NC, Arzubi E. Prospective, Open Trial of Adjunctive Triple Chronotherapy for the Acute Treatment of Depression in Adolescent Inpatients. J Child Adolesc Psychopharmacol 2019; 29:20-27. [PMID: 30388037 DOI: 10.1089/cap.2018.0063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this pilot study was to explore the feasibility and proof of concept of triple chronotherapy (TCT) as a nonpharmacological adjunctive treatment in the acute management of depression in the adolescent population. METHODS Thirty-one adolescents with nonpsychotic moderate-to-severe depression were included in the study. The 4-day TCT intervention comprised one night of sleep deprivation followed by 3 days of sleep phase advancement and daily bright light therapy. Primary outcomes were feasibility and depression, as measured by the Hamilton Depression Scale-17 (HAMD-17). Secondary outcomes included severity of illness, anxiety, self-harm, insomnia, and suicidality. RESULTS Twenty-nine (94%) adolescents completed the 4-day TCT intervention. Twenty-six (84%) of the 31 enrolled patients experienced a reduction in depressive symptoms of at least 50% from baseline; 24 (77%) achieved remission, defined as a HAMD-17 score less than 8. The mean depression score was severe before the start of the intervention ( \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 21.8 ± 3.8) and dropped below the remission threshold by day 4 ( \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 4.4 ± 5.1; p < 0.001); the mean depression score was mild at 1 week (n = 17; \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 9.3 ± 5.2; p < 0.001) and 1 month (n = 10, \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 7.8 ± 5.2; p < 0.001). Severity of illness scores according to the Clinical Global Impressions severity subscale improved from a mean of 5.3 at baseline to 3.1 following the TCT intervention (p < 0.0001); the effect was sustained through the 1-week postdischarge and the 1-month follow-up. Secondary outcomes showed significant improvement following the 4-day TCT intervention; improvement was sustained through the 1-week and 1-month follow-up periods. CONCLUSIONS This pilot study determined TCT to be a feasible, safe, rapid, and potentially effective adjunctive treatment for depression in the adolescent population.
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Affiliation(s)
- Diane Hurd
- 1 Department of Psychiatry, Billings Clinic , Billings, Montana
| | - Mariela Herrera
- 1 Department of Psychiatry, Billings Clinic , Billings, Montana
| | - Jeannine M Brant
- 2 Collaborative Science & Innovation, Billings Clinic , Billings, Montana
| | - Nicholas C Coombs
- 2 Collaborative Science & Innovation, Billings Clinic , Billings, Montana
| | - Eric Arzubi
- 1 Department of Psychiatry, Billings Clinic , Billings, Montana
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Maruani J, Geoffroy PA. Bright Light as a Personalized Precision Treatment of Mood Disorders. Front Psychiatry 2019; 10:85. [PMID: 30881318 PMCID: PMC6405415 DOI: 10.3389/fpsyt.2019.00085] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 02/06/2019] [Indexed: 01/10/2023] Open
Abstract
Background: The use of light for its antidepressant action dates back to the beginnings of civilization. Three decades ago, the use of bright-light therapy (BLT) for treating Seasonal Affective Disorder (SAD) was officially proposed. Since then, a growing scientific literature reports its antidepressant efficacy in both unipolar and bipolar disorders (BD), with or without seasonal patterns. This review aims to examine the management of BLT as a personalized and precision treatment in SAD, unipolar, and BD. Methods: We conducted a narrative review using Medline and Google Scholar databases up to June 2018. Results: BLT has physiological effects by resynchronizing the biological clock (circadian system), enhancing alertness, increasing sleep pressure (homeostatic system), and acting on serotonin, and other monoaminergic pathways. Effects of BLT on mood depend on several factors such as light intensity, wavelength spectrum, illumination duration, time of the day, and individual circadian rhythms. A growing body of evidence has been generated over the last decade about BLT evolving as an effective depression treatment not only to be used in SAD, but also in non-seasonal depression, with efficiency comparable to fluoxetine, and possibly more robust in patients with BD. The antidepressant action of BLT is fast (within 1-week) and safe, with the need in BD to protect against manic switch with mood stabilizers. Side effects might be nausea, diarrhea, headache, and eye irritation, and are generally mild and rare. This good safety profile may be of particular interest, especially in women during the perinatal period or for the elderly. The management of BLT needs to be clarified across mood disorders and future studies are expected to compare different dose-titration protocols, to validate its use as a maintenance treatment, and also to identify predictive biomarkers of response and tolerability. We propose clinical guidelines for BLT use in SAD, non-seasonal depression, and BD. Conclusions : BLT is an efficient antidepressant strategy in mono- or adjunct-therapy, that should be personalized according the unipolar or bipolar subtype, the presence or absence of seasonal patterns, and also regarding its efficacy and tolerability.
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Affiliation(s)
- Julia Maruani
- Inserm, U1144, Paris, France.,Université Paris Descartes, UMR-S 1144, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, France.,AP-HP, GH Saint-Louis-Lariboisière-F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, Paris, France
| | - Pierre Alexis Geoffroy
- Inserm, U1144, Paris, France.,Université Paris Descartes, UMR-S 1144, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UMR-S 1144, Paris, France.,AP-HP, GH Saint-Louis-Lariboisière-F. Widal, Pôle de Psychiatrie et de Médecine Addictologique, Paris, France
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Asai Y, Obayashi K, Oume M, Ogura M, Takeuchi K, Yamagami Y, Tai Y, Kurumatani N, Saeki K. Farming habit, light exposure, physical activity, and depressive symptoms. A cross-sectional study of the HEIJO-KYO cohort. J Affect Disord 2018; 241:235-240. [PMID: 30138807 DOI: 10.1016/j.jad.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 07/12/2018] [Accepted: 08/03/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bright light therapy and exercise interventions are effective methods for treating seasonal and non-seasonal affective disorders. Synchronization of internal circadian rhythms with the external environment by light therapy and physical activity may partly explain its efficacy. In the present study, we objectively measured daytime light exposure and physical activity in real life situations with elderly participants, and investigated the association between farming habits and the prevalence of depressive symptoms. METHODS This cross-sectional was conducted among 1005 participants (mean age: 71.5) of a community-based cohort study. Depressive symptoms were assessed by the Geriatric Depression Scale (GDS score ≥ 6) and administration of antidepressant. RESULTS Farming habit with long duration (> 7.0 h/week) showed significantly lower odds ratios (OR) for depressive symptoms (adjusted OR 0.63, 95% confidential interval,0.41 to 0.96) compared with participants without farming habit independent of confounders such as age, gender, body mass index smoking, drinking, daytime ambulatory systolic blood pressure, diabetes, living alone, education, income, and daylength. Even in farming with short duration (≤ 7.0 h/week), we found significant association with lower OR for depressive symptoms (adjusted OR 0.64, 95%CI, 0.42 to 0.97). Light exposure and daytime physical activity measured by wrist actigraphy were significantly higher among participants with longer farming habits (p for trend < 0.01). Physical activity mediated 12.0% of association between farming habit and depressive symptoms. LIMITATIONS A cross-sectional association may be found because the participants with depressive symptoms tended to avoid farming. A longitudinal study is warranted to determine the direction of causality. CONCLUSIONS Participants with farming habit showed significantly lower OR for depressive symptoms than those without farming habit, and it was partly mediated by physical activity.
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Affiliation(s)
- Yuji Asai
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Kenji Obayashi
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Masataka Oume
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Moe Ogura
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Katsuya Takeuchi
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Yuki Yamagami
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Yoshiaki Tai
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan; Department of General Medicine, Nara Medical University School of Medicine, Nara, Japan
| | - Norio Kurumatani
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Keigo Saeki
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan.
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Holtmann M, Mokros L, Kirschbaum-Lesch I, Kölch M, Plener PL, Ruckes C, Schulte-Markwort M, Legenbauer T. Adolescent depression: Study protocol for a randomized, controlled, double-blind multicenter parallel group trial of Bright Light Therapy in a naturalistic inpatient setting (DeLight). Trials 2018; 19:568. [PMID: 30340625 PMCID: PMC6194631 DOI: 10.1186/s13063-018-2949-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 09/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depressive disorders are among the most prominent health problems in youth. Even with the best available pharmacological and non-pharmacological treatments, remission rates are low. Without early treatment, depression in youth is associated with a high risk of symptom progression, chronicity, co-morbidity, and suicidal behavior. Thus, adolescent depression is a prime candidate for innovation in treatment. In depressive adults, meta-analytic evidence has proven that bright light therapy (BLT) is a potent low-threshold intervention, promising due to easy application, low side effects, and optimized compliance. In adolescents, studies with small samples show promising effects. This randomized controlled trial will examine the effectiveness of BLT in youth inpatients. METHODS/DESIGN In this randomized, controlled, double-blind multicenter parallel group trial, morning BLT is applied for four weeks in addition to treatment as usual (TAU) for depressed youth inpatients (daily morning exposure to bright light via light-emitting glasses, 10,000 lx, for 30 min) and will be compared to a control condition (placebo light treatment, red light, identical light glasses). The primary objective is to assess whether BLT reduces symptoms of depression in youth with greater effect compared to placebo light therapy. Secondary objectives are to examine the impact of BLT on responder status, application of antidepressant medication, and further depression-related symptoms (sleep, activity, quality of life, satisfaction with health, general psychopathology, alertness, and circadian function). N = 224 patients will be recruited in a naturalistic inpatient setting. A follow-up will be carried out after three and six months. DISCUSSION The study aims to discuss and evaluate BLT as an additive method supporting standardized clinical procedures dealing with severe to moderate depressive symptoms in youth. TRIAL REGISTRATION German Clinical Trials Register, DRKS00013188 . Registered on November 30, 2017.
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Affiliation(s)
- Martin Holtmann
- Clinic for Child and Adolescent Psychiatry, LWL University Hospital Hamm of the Ruhr-University Bochum, Heithofer Allee 64, 59071 Hamm, Germany
| | - Laura Mokros
- Clinic for Child and Adolescent Psychiatry, LWL University Hospital Hamm of the Ruhr-University Bochum, Heithofer Allee 64, 59071 Hamm, Germany
| | - Inken Kirschbaum-Lesch
- Clinic for Child and Adolescent Psychiatry, LWL University Hospital Hamm of the Ruhr-University Bochum, Heithofer Allee 64, 59071 Hamm, Germany
| | - Michael Kölch
- Department Child and Adolescent Psychiatry and Psychotherapy, Brandenburg Medical School, Neuruppin, Germany
| | - Paul L. Plener
- Department of Child and Adolescent Psychiatry and Psychotherapy, Ulm University, Ulm, Germany
| | - Christian Ruckes
- Interdisciplinary Centre for Clinical Trials, Mainz University, Mainz, Germany
| | | | - Tanja Legenbauer
- Clinic for Child and Adolescent Psychiatry, LWL University Hospital Hamm of the Ruhr-University Bochum, Heithofer Allee 64, 59071 Hamm, Germany
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Morton DP. Combining Lifestyle Medicine and Positive Psychology to Improve Mental Health and Emotional Well-being. Am J Lifestyle Med 2018; 12:370-374. [PMID: 30283261 PMCID: PMC6146362 DOI: 10.1177/1559827618766482] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Darren P. Morton
- Lifestyle Research Centre, Avondale College of Higher Education, Cooranbong, NSW, Australia
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Time of Administration of Acute or Chronic Doses of Imipramine Affects its Antidepressant Action in Rats. J Circadian Rhythms 2018; 16:5. [PMID: 30210565 PMCID: PMC6083812 DOI: 10.5334/jcr.156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The pathogenesis and therapeutics of depression are linked to the operation of the circadian system. Here, we studied the chronopharmacological action of a tricyclic antidepressant, imipramine. Male adult Wistar–Hannover rats were administered imipramine acutely or chronically in the morning or in the evening. The antidepressant action of imipramine was analyzed using the forced swim test (FST). A single dose of imipramine (30 mg/kg) in the morning, but not in the evening, reduced immobility and increased climbing in the FST. The plasma concentrations of imipramine and its metabolite, desipramine, were slightly higher in the morning than in the evening, which might explain the dosing time-dependent action of imipramine. Next, we analyzed the effect of chronic imipramine treatment. Rats received imipramine in the morning or in the evening for 2 weeks. The morning treatment resulted in larger effects in the FST than the evening treatment, and was effective at a dose that was ineffective when administered acutely. The levels of brain α-adrenergic receptors tended to decrease after chronic imipramine treatment. Imipramine might interact with noradrenergic neurons, and this interaction might chronically alter receptor expression. This alteration seemed greater in the morning than in the evening, which might explain the dosing time-dependent action of imipramine.
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Zhao X, Ma J, Wu S, Chi I, Bai Z. Light therapy for older patients with non-seasonal depression: A systematic review and meta-analysis. J Affect Disord 2018; 232:291-299. [PMID: 29500957 DOI: 10.1016/j.jad.2018.02.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 11/30/2017] [Accepted: 02/16/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Light therapy has become an increasingly common treatment for adults with depression, yet the role of light therapy for non-seasonal depression among older adults remains unclear. OBJECTIVE This meta-analysis sought to evaluate the effectiveness of light therapy among older patients with non-seasonal depression. METHODS We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science, CNKI and CBM from the inception of each database to May 2017. Two researchers conducted the literature screening, data extraction, and methodological quality assessment independently. We used the Cochrane Collaboration's bias assessment tool to evaluate the risk of bias for included studies, and Review Manager 5.2.3 Software for the meta-analysis. RESULTS Six trials with a total of 359 patients were included, and five studies were assessed as being of low risk for bias. We evaluated the effect of light therapy on depression by the reduction of depressive symptoms (SMD = 0.45; 95% CI= [0.14, 0.75]). The subgroup analysis did not find significant moderating effects of depression with intervention intensity, light type, measuring scale or intervention duration. LIMITATIONS Most of the study samples were not representative of the larger population of adults and therefore caution should be used when interpreting the findings. CONCLUSIONS Light therapy has a positive effect on geriatric non-seasonal depression. Studies with larger sample sizes are needed to confirm the curative effect of light therapy in the future.
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Affiliation(s)
- Xue Zhao
- Evidence-Based Social Science & Health Decision Research Center, Public Affair School, Nanjing University of Science & Technology; The Second Clinic School of Lanzhou University, Lanzhou, China
| | - Jing Ma
- Department of Endocrinology, Gansu Provincial Hospital, Lanzhou, China
| | - Shiyou Wu
- School of Social Work, Arizona State University, Phoenix, AZ, USA
| | - Iris Chi
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, USA
| | - Zhenggang Bai
- Evidence-Based Social Science & Health Decision Research Center, Public Affair School, Nanjing University of Science & Technology, Nanjing 210000, China..
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Zhou TH, Dang WM, Ma YT, Hu CQ, Wang N, Zhang GY, Wang G, Shi C, Zhang H, Guo B, Zhou SZ, Feng L, Geng SX, Tong YZ, Tang GW, He ZK, Zhen L, Yu X. Clinical efficacy, onset time and safety of bright light therapy in acute bipolar depression as an adjunctive therapy: A randomized controlled trial. J Affect Disord 2018; 227:90-96. [PMID: 29053981 DOI: 10.1016/j.jad.2017.09.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 07/20/2017] [Accepted: 09/23/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Bright light therapy (BLT) is an effective treatment for seasonal affective disorder and non- seasonal depression. The efficacy of BLT in treating patients with bipolar disorder is still unknown. AIMS The aim of this study is to examine the efficacy, onset time and clinical safety of BLT in treating patients with acute bipolar depression as an adjunctive therapy (trial registration at ClinicalTrials.gov: NCT02009371). METHODS This was a multi-center, single blind, randomized clinical trial. Seventy-four participants were randomized in one of two treatment conditions: BLT and control (dim red light therapy, dRLT). Sixty-three participants completed the study (33 BLT, 30 dRLT). Light therapy lasted for two weeks, one hour every morning. All participants were required to complete several scales assessments at baseline, and at the end of weeks 1 and 2. The primary outcome measures were the clinical efficacy of BLT which was assessed by the reduction rate of HAMD-17 scores, and the onset time of BLT which was assessed by the reduction rate of QIDS-SR16 scores. The secondary outcome measures were rates of switch into hypomania or mania and adverse events. RESULTS 1) Clinical efficacy: BLT showed a greater ameliorative effect on bipolar depression than the control, with response rates of 78.19% vs. 43.33% respectively (p < 0.01). 2) Onset day: Median onset day was 4.33 days in BLT group. 3) BLT-emergent hypomania: No participants experienced symptoms of hypomania. 4) Side effects: No serious adverse events were reported. CONCLUSION BLT can be considered as an effective and safe adjunctive treatment for patients with acute bipolar depression.
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Affiliation(s)
- Tian-Hang Zhou
- Peking University Sixth Hospital, Peking University Institute of Mental Health, the Key Laboratory of the Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders, Beijing, China
| | - Wei-Min Dang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, the Key Laboratory of the Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders, Beijing, China
| | - Yan-Tao Ma
- Peking University Sixth Hospital, Peking University Institute of Mental Health, the Key Laboratory of the Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders, Beijing, China
| | - Chang-Qing Hu
- Mood Disorders Center, Beijing Anding Hospital, Capital Medical University & China Clinical Research Center for Mental Disorders Center of Depression, Beijing Institute for Brain Disorders, Beijing, China
| | - Ning Wang
- Beijing Huilongguan Hospital, Peking University, Beijing, China
| | - Guo-Yi Zhang
- School of physics, Peking University, Beijing, China
| | - Gang Wang
- Mood Disorders Center, Beijing Anding Hospital, Capital Medical University & China Clinical Research Center for Mental Disorders Center of Depression, Beijing Institute for Brain Disorders, Beijing, China
| | - Chuan Shi
- Peking University Sixth Hospital, Peking University Institute of Mental Health, the Key Laboratory of the Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders, Beijing, China
| | - Hua Zhang
- Peking University Third Hospital, Beijing, China
| | - Bin Guo
- Beijing Huilongguan Hospital, Peking University, Beijing, China
| | - Shu-Zhe Zhou
- Peking University Sixth Hospital, Peking University Institute of Mental Health, the Key Laboratory of the Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders, Beijing, China
| | - Lei Feng
- Mood Disorders Center, Beijing Anding Hospital, Capital Medical University & China Clinical Research Center for Mental Disorders Center of Depression, Beijing Institute for Brain Disorders, Beijing, China
| | - Shu-Xia Geng
- Peking University Sixth Hospital, Peking University Institute of Mental Health, the Key Laboratory of the Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders, Beijing, China
| | - Yu-Zhen Tong
- School of physics, Peking University, Beijing, China
| | - Guan-Wen Tang
- Beijing Huilongguan Hospital, Peking University, Beijing, China
| | - Zhong-Kai He
- School of physics, Peking University, Beijing, China
| | - Long Zhen
- Mood Disorders Center, Beijing Anding Hospital, Capital Medical University & China Clinical Research Center for Mental Disorders Center of Depression, Beijing Institute for Brain Disorders, Beijing, China
| | - Xin Yu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, the Key Laboratory of the Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders, Beijing, China.
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Precision Light for the Treatment of Psychiatric Disorders. Neural Plast 2018; 2018:5868570. [PMID: 29593784 PMCID: PMC5821959 DOI: 10.1155/2018/5868570] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/05/2017] [Indexed: 01/07/2023] Open
Abstract
Circadian timekeeping can be reset by brief flashes of light using stimulation protocols thousands of times shorter than those previously assumed to be necessary for traditional phototherapy. These observations point to a future where flexible architectures of nanosecond-, microsecond-, and millisecond-scale light pulses are compiled to reprogram the brain's internal clock when it has been altered by psychiatric illness or advanced age. In the current review, we present a chronology of seminal experiments that established the synchronizing influence of light on the human circadian system and the efficacy of prolonged bright-light exposure for reducing symptoms associated with seasonal affective disorder. We conclude with a discussion of the different ways that precision flashes could be parlayed during sleep to effect neuroadaptive changes in brain function. This article is a contribution to a special issue on Circadian Rhythms in Regulation of Brain Processes and Role in Psychiatric Disorders curated by editors Shimon Amir, Karen Gamble, Oliver Stork, and Harry Pantazopoulos.
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Brown GM, McIntyre RS, Rosenblat J, Hardeland R. Depressive disorders: Processes leading to neurogeneration and potential novel treatments. Prog Neuropsychopharmacol Biol Psychiatry 2018; 80:189-204. [PMID: 28433459 DOI: 10.1016/j.pnpbp.2017.04.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/01/2017] [Indexed: 12/18/2022]
Abstract
Mood disorders are wide spread with estimates that one in seven of the population are affected at some time in their life (Kessler et al., 2012). Many of those affected with severe depressive disorders have cognitive deficits which may progress to frank neurodegeneration. There are several peripheral markers shown by patients who have cognitive deficits that could represent causative factors and could potentially serve as guides to the prevention or even treatment of neurodegeneration. Circadian rhythm misalignment, immune dysfunction and oxidative stress are key pathologic processes implicated in neurodegeneration and cognitive dysfunction in depressive disorders. Novel treatments targeting these pathways may therefore potentially improve patient outcomes whereby the primary mechanism of action is outside of the monoaminergic system. Moreover, targeting immune dysfunction, oxidative stress and circadian rhythm misalignment (rather than primarily the monoaminergic system) may hold promise for truly disease modifying treatments that may prevent neurodegeneration rather than simply alleviating symptoms with no curative intent. Further research is required to more comprehensively understand the contributions of these pathways to the pathophysiology of depressive disorders to allow for disease modifying treatments to be discovered.
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Affiliation(s)
- Gregory M Brown
- Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, 250 College St. Toronto, ON M5T 1R8, Canada.
| | - Roger S McIntyre
- Psychiatry and Pharmacology, University of Toronto, Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada.
| | - Joshua Rosenblat
- Resident of Psychiatry, Clinician Scientist Stream, University of Toronto, Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada
| | - Rüdiger Hardeland
- Johann Friedrich Blumenbach Institut für Zoologie und Anthropologie, Universität Göttingen, Buergerstrasse 50, D-37073 Göttingen, Germany.
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Abstract
Light improves cognitive function in humans; however, the neurobiological mechanisms underlying positive effects of light remain unclear. One obstacle is that most rodent models have employed lighting conditions that cause cognitive deficits rather than improvements. Here we have developed a mouse model where light improves cognitive function, which provides insight into mechanisms underlying positive effects of light. To increase light exposure without eliminating daily rhythms, we exposed mice to either a standard photoperiod or a long day photoperiod. Long days enhanced long-term recognition memory, and this effect was abolished by loss of the photopigment melanopsin. Further, long days markedly altered hippocampal clock function and elevated transcription of Insulin-like Growth Factor2 (Igf2). Up-regulation of Igf2 occurred in tandem with suppression of its transcriptional repressor Wilm’s tumor1. Consistent with molecular de-repression of Igf2, IGF2 expression was increased in the hippocampus before and after memory training. Lastly, long days occluded IGF2-induced improvements in recognition memory. Collectively, these results suggest that light changes hippocampal clock function to alter memory, highlighting novel mechanisms that may contribute to the positive effects of light. Furthermore, this study provides insight into how the circadian clock can regulate hippocampus-dependent learning by controlling molecular processes required for memory consolidation.
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Abstract
BACKGROUND The purpose of this paper is to describe variation, over the months of the year, in major depressive episode (MDE) prevalence. This is an important aspect of the epidemiological description of MDE, and one that has received surprisingly little attention in the literature. Evidence of seasonal variation in MDE prevalence has been weak and contradictory. Most studies have sought to estimate the prevalence of seasonal affective disorder using cut-points applied to scales assessing mood seasonality rather than MDE. This approach does not align with modern classification in which seasonal depression is a diagnostic subtype of major depression rather than a distinct category. Also, some studies may have lacked power to detect seasonal differences. We addressed these limitations by examining the month-specific occurrence of conventionally defined MDE and by pooling data from large epidemiological surveys to enhance precision in the analysis. METHOD Data from two national survey programmes (the National Population Health Survey and the Canadian Community Health Survey) were used, providing ten datasets collected between 1996 and 2013, together including over 500,000. These studies assessed MDE using a short form version of the Composite International Diagnostic Interview (CIDI) for major depression, with one exception being a 2012 survey that used a non-abbreviated version of the CIDI. The proportion of episodes occurring in each month was evaluated using items from the diagnostic modules and statistical methods addressing complex design features of these trials. Overall month-specific pooled estimates and associated confidence intervals were estimated using random effects meta-analysis and a gradient was assessed using a meta-regression model that included a quadratic term. RESULTS There was considerable sampling variability when the month-specific proportions were estimated from individual survey datasets. However, across the various datasets, there was sufficient homogeneity to justify the pooling of these estimated proportions, producing large gains in precision. Seasonal variation was clearly evident in the pooled data. The highest proportion of episodes occurred in December, January and February and the lowest proportions occurred in June, July and August. The proportion of respondents reporting MDE in January was 70% higher than August, suggesting an association with implications for health policy. The pattern persisted with stratification for age group, sex and latitude. CONCLUSIONS Seasonal effects in MDE may have been obscured by small sample sizes in prior studies. In Canada, MDE has clear seasonal variation, yet this is not addressed in the planning of services. These results suggest that availability of depression treatment should be higher in the winter than the summer months.
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Bais B, Kamperman AM, van der Zwaag MD, Dieleman GC, Harmsen van der Vliet-Torij HW, Bijma HH, Lieverse R, Hoogendijk WJG, Lambregtse-van den Berg MP. Bright light therapy in pregnant women with major depressive disorder: study protocol for a randomized, double-blind, controlled clinical trial. BMC Psychiatry 2016; 16:381. [PMID: 27821114 PMCID: PMC5100252 DOI: 10.1186/s12888-016-1092-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/26/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Depression during pregnancy is a common and high impact disease. Generally, 5-10 % of pregnant women suffer from depression. Children who have been exposed to maternal depression during pregnancy have a higher risk of adverse birth outcomes and more often show cognitive, emotional and behavioural problems. Therefore, early detection and treatment of antepartum depression is necessary. Both psychotherapy and antidepressant medication, first choice treatments in a non-pregnant population, have limitations in treating depression during pregnancy. Therefore, it is urgent and relevant to investigate alternative treatments for antepartum depression. Bright light therapy (BLT) is a promising treatment for pregnant women with depressive disorder, for it combines direct availability, sufficient efficacy, low costs and high safety, taking the safety for the unborn child into account as well. METHODS In this study, 150 pregnant women (12-18 weeks pregnant) with a DSM-V diagnosis of depressive disorder will be randomly allocated in a 1:1 ratio to one of the two treatment arms: treatment with BLT (9.000 lux) or treatment with dim red light therapy (100 lux). Both groups will be treated for 6 weeks at home on a daily basis for 30 min, within 30 min of habitual wake-up time. Follow-up will take place after 6 weeks of therapy, 3 and 10 weeks after end of therapy, at birth and 2, 6 and 18 months postpartum. Primary outcome will be the average change in depressive symptoms between the two groups, as measured by the Structured Interview Guide for the Hamilton Depression Scale - Seasonal Affective Disorder version and the Edinburg Postnatal Depression Scale. Changes in rating scale scores of these questionnaires over time will be analysed using generalized linear mixed models. Secondary outcomes will be the changes in maternal cortisol and melatonin levels, in maternal sleep quality and gestational age, birth weight, infant behaviour, infant cortisol exposure and infant cortisol stress response. DISCUSSION If BLT reduces depressive symptoms in pregnant women, it will provide a safe, cheap, non-pharmacological and efficacious alternative treatment for psychotherapy and antidepressant medication in treating antepartum depression, without any expected adverse reactions for the unborn child. TRIAL REGISTRATION Netherlands Trial Register NTR5476 . Registered 5 November 2015.
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Affiliation(s)
- Babette Bais
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, 's Gravendijkwal 230, 3015CE, Rotterdam, The Netherlands.
| | - Astrid M. Kamperman
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, ‘s Gravendijkwal 230, 3015CE Rotterdam, The Netherlands ,Epidemiological and Social Psychiatric Research Institute, Erasmus University Medical Centre Rotterdam, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | | | - Gwen C. Dieleman
- Department of Child and Adolescent Psychiatry, Erasmus University Medical Centre Rotterdam, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | | | - Hilmar H. Bijma
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre Rotterdam, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Ritsaert Lieverse
- Department of Psychiatry and Psychology, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Witte J. G. Hoogendijk
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, ‘s Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
| | - Mijke P. Lambregtse-van den Berg
- Department of Psychiatry, Erasmus University Medical Centre Rotterdam, ‘s Gravendijkwal 230, 3015CE Rotterdam, The Netherlands ,Department of Child and Adolescent Psychiatry, Erasmus University Medical Centre Rotterdam, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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Rutten S, Vriend C, Smit JH, Berendse HW, Hoogendoorn AW, van den Heuvel OA, van der Werf YD. A double-blind randomized controlled trial to assess the effect of bright light therapy on depression in patients with Parkinson's disease. BMC Psychiatry 2016; 16:355. [PMID: 27769202 PMCID: PMC5073442 DOI: 10.1186/s12888-016-1050-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 09/24/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND A disturbed circadian rhythm seems to be a causal factor in the occurrence of depressive disorders in patients with Parkinson's disease (PD). The circadian rhythm can be restored with light. Therefore, Bright Light Therapy (BLT) might be a new treatment option for depression in PD patients. METHODS/DESIGN In this double-blind controlled trial, 84 subjects with idiopathic PD are randomized to either BLT or a control light condition. The BLT condition emits white light with an intensity of 10,000 Lux, while the control device emits dim white light of 200 Lux, which is presumed to be too low to influence the circadian rhythm. Subjects receive 30 min of home treatment twice daily for three months. Timing of treatment is based on the individual chronotype. After finishing treatment, subjects enter a follow-up period of six months. The primary outcome of the study is the severity of depressive symptoms, as measured with the Hamilton Depression Rating Scale. Secondary outcomes are alternative depression measures, objective and subjective sleep measures, and salivary melatonin and cortisol concentrations. For exploratory purposes, we also assess the effects on motor symptoms, global cognitive function, comorbid psychiatric disorders, quality of life and caregiver burden. Data will be analyzed using a linear mixed models analysis. DISCUSSION Performing a placebo-controlled trial on the effects of BLT in PD patients is challenging, as the appearance of the light may provide clues on the treatment condition. Moreover, fixed treatment times lead to an improved sleep-wake rhythm, which also influences the circadian system. With our study design, we do not compare BLT to placebo treatment, i.e. an ineffective control treatment. Rather, we compare structuring of the sleep-wake cycle in both conditions with additional BLT in the experimental condition, and additional dim light in the control condition. Participants are not informed about the exact details of the two light devices and the expected therapeutic effect, and expectancies are rated prior to the start of treatment. Ideally, the design of a future study on BLT should include two extra treatment arms where BLT and control light are administered at random times. TRIAL REGISTRATION This trial was registered on ClinicalTrials.gov on May 17th 2012 (ClinicalTrials.gov Identifier: NCT01604876 ).
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Affiliation(s)
- Sonja Rutten
- Department of Psychiatry, VU University Medical Center/GGZ inGeest, A.J. Ernststraat 887, 1081 HL, Amsterdam, The Netherlands. .,Department of Anatomy and Neurosciences, VU University Medical Center, Gustav Mahlerlaan 3004, 1000 MB, Amsterdam, The Netherlands.
| | - Chris Vriend
- Department of Psychiatry, VU University Medical Center/GGZ inGeest, A.J. Ernststraat 887, 1081 HL Amsterdam, The Netherlands ,Department of Anatomy and Neurosciences, VU University Medical Center, Gustav Mahlerlaan 3004, 1000 MB Amsterdam, The Netherlands ,Amsterdam Neuroscience, de Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Jan H. Smit
- Department of Psychiatry, VU University Medical Center/GGZ inGeest, A.J. Ernststraat 887, 1081 HL Amsterdam, The Netherlands ,Amsterdam Neuroscience, de Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Henk W. Berendse
- Amsterdam Neuroscience, de Boelelaan 1085, 1081 HV Amsterdam, The Netherlands ,Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Adriaan W. Hoogendoorn
- Department of Psychiatry, VU University Medical Center/GGZ inGeest, A.J. Ernststraat 887, 1081 HL Amsterdam, The Netherlands
| | - Odile A. van den Heuvel
- Department of Psychiatry, VU University Medical Center/GGZ inGeest, A.J. Ernststraat 887, 1081 HL Amsterdam, The Netherlands ,Department of Anatomy and Neurosciences, VU University Medical Center, Gustav Mahlerlaan 3004, 1000 MB Amsterdam, The Netherlands ,Amsterdam Neuroscience, de Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Ysbrand D. van der Werf
- Department of Anatomy and Neurosciences, VU University Medical Center, Gustav Mahlerlaan 3004, 1000 MB Amsterdam, The Netherlands ,Amsterdam Neuroscience, de Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
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Eniola K, Bacigalupo A, Mounsey A. PURLs: Light therapy for nonseasonal major depressive disorder? THE JOURNAL OF FAMILY PRACTICE 2016; 65:486-488. [PMID: 27565102 PMCID: PMC4980118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
While bright light therapy already has a place in the treatment of seasonal affective disorder, a recent trial spotlights its utility beyond the winter months.
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Affiliation(s)
- Kehinde Eniola
- Cone Health Family Medicine Residency, Greensboro, NC, USA
| | | | - Anne Mounsey
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC, USA
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[The current state of research in bright light therapy]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2016; 27:142-8. [PMID: 23793981 DOI: 10.1007/s40211-013-0067-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 04/05/2013] [Indexed: 01/22/2023]
Abstract
The significance of light for the human organism and especially for the mental health is well-established for a long time. Therefore, the impact of light on mood and the use of bright light as a treatment-option for affective disorders have been studied extensively by scientists. Today bright light therapy is the treatment of choice for saisonal affective disorders. In the last years several clinical trials could demonstrate the therapeutic efficacy of bright light therapy for different neurological and psychiatric disorders such as sleep disorders, non-seasonal affective disorders or dementia. This article will give an overview about the neurobiological basis for light therapy and discuss different disorders responsive to light therapy. Finally a short overview about technical aspects of light therapy and new developments in light engineering will be presented.
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Combined non-adaptive light and smell stimuli lowered blood pressure, reduced heart rate and reduced negative affect. Physiol Behav 2016; 156:94-105. [DOI: 10.1016/j.physbeh.2016.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/07/2016] [Accepted: 01/12/2016] [Indexed: 12/27/2022]
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Perera S, Eisen R, Bhatt M, Bhatnagar N, de Souza R, Thabane L, Samaan Z. Light therapy for non-seasonal depression: systematic review and meta-analysis. BJPsych Open 2016; 2:116-126. [PMID: 27703764 PMCID: PMC4998929 DOI: 10.1192/bjpo.bp.115.001610] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 12/02/2015] [Accepted: 12/21/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Light therapy is a known treatment for patients with seasonal affective disorder. However, the efficacy of light therapy in treating patients with non-seasonal depression remains inconclusive. AIMS To provide the current state of evidence for efficacy of light therapy in non-seasonal depressive disorders. METHOD Systematic review of randomised controlled trials (RCTs) was conducted by searching MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL from their inception to September 2015. Study selection, data abstraction and risk of bias assessment were independently conducted in duplicate. Meta-analyses were performed to provide a summary statistic for the included RCTs. The reporting of this systematic review follows the PRISMA guidelines. RESULTS A meta-analysis including 881 participants from 20 RCTs demonstrated a beneficial effect of light therapy in non-seasonal depression (standardised mean difference in depression score -0.41 (95% CI -0.64 to -0.18)). This estimate was associated with significant heterogeneity (I2=60%, P=0.0003) that was not sufficiently explained by subgroup analyses. There was also high risk of bias in the included trials limiting the study interpretation. CONCLUSIONS The overall quality of evidence is poor due to high risk of bias and inconsistency. However, considering that light therapy has minimal side-effects and our meta-analysis demonstrated that a significant proportion of patients achieved a clinically significant response, light therapy may be effective for patients with non-seasonal depression and can be a helpful additional therapeutic intervention for depression. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Stefan Perera
- Stefan Perera, BSc, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Rebecca Eisen
- Rebecca Eisen, BHSc, MiNDS Neuroscience Graduate Program, McMaster University, Hamilton, Canada
| | - Meha Bhatt
- Meha Bhatt, BSc, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Neera Bhatnagar
- Neera Bhatnagar, MLIS, Health Sciences Library, McMaster University, Hamilton, Canada
| | - Russell de Souza
- Russell de Souza, ScD, RD, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Lehana Thabane, PhD, McMaster University, Hamilton, Canada; Biostatistics Unit, Centre for Evaluation of Medicine, Hamilton, Canada
| | - Zainab Samaan
- Zainab Samaan, MBChB, MRCPsych, PhD, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; Biostatistics Unit, Centre for Evaluation of Medicine, Hamilton, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
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Keller LK, Zöschg S, Grünewald B, Roenneberg T, Schulte-Körne G. Chronotyp und Depression bei Jugendlichen – ein Review. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2016; 44:113-26. [DOI: 10.1024/1422-4917/a000406] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Zusammenfassung. Depressive Erkrankungen gehen mit vielen Symptomen einher, die in Bezug zu einer tageszeitlichen Rhythmik und dem Schlafverhalten stehen. Die vielfältigen Zusammenhänge zwischen Schlaf, Depression und Tagesrhythmik sind nicht eindeutig geklärt. In den Forschungsarbeiten der letzten Jahre kommt dem Chronotyp eine besondere Bedeutung zu. Als biologisches Maß der inneren Uhr kann der Chronotyp – basierend auf Schlafzeiten – mit dem Munich ChronoType Questionnaire (MCTQ) bestimmt werden, als subjektive Präferenz für bestimmte Tageszeiten wird er mit dem Morningness-Eveningness-Questionnaire (MEQ) erfasst. Durch eine systematische Literaturrecherche konnten Studien identifiziert werden, die überwiegend einen Zusammenhang zwischen einem späten Chronotyp und depressiven Symptomen und depressiven Störungen zeigen. Dies ist besonders für Jugendliche relevant, da sich der Chronotyp zur Adoleszenz hin stark verändert. Bisher ist nicht geklärt, was am Zusammenhang zwischen Chronotyp und depressiver Störung Ursache und Wirkung ist und welche Faktoren als Moderator oder Mediator fungieren. Möglicherweise ist der Zusammenhang bidirektional: Einerseits ziehen sich Patienten mit depressiven Störungen häufig zurück und sind weniger Tageslicht ausgesetzt, was ihren Chronotyp später werden lässt. Andererseits führt eine Diskrepanz von Innenzeit (festgelegt durch die innere Uhr) und Außenzeit (z. B. durch Schul- und Arbeitszeiten) zu Problemen wie einer verringerten Schlafqualität und schlechteren Schulnoten, die wiederum im Zusammenhang mit Depressivität stehen können.
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Affiliation(s)
- Lena Katharina Keller
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Klinikum der Universität München
- Institut für Medizinische Psychologie, Zentrum für Chronobiologie, Ludwig-Maximilians-Universität München
- Geteilte Erstautorenschaft
| | - Sarah Zöschg
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Klinikum der Universität München
- Geteilte Erstautorenschaft
| | - Barbara Grünewald
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Klinikum der Universität München
| | - Till Roenneberg
- Institut für Medizinische Psychologie, Zentrum für Chronobiologie, Ludwig-Maximilians-Universität München
| | - Gerd Schulte-Körne
- Klinik und Poliklinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Klinikum der Universität München
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Gertler P, Tate RL, Cameron ID. Non-pharmacological interventions for depression in adults and children with traumatic brain injury. Cochrane Database Syst Rev 2015; 2015:CD009871. [PMID: 26663136 PMCID: PMC8761477 DOI: 10.1002/14651858.cd009871.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Following traumatic brain injury (TBI) there is an increased prevalence of depression compared to the general population. It is unknown whether non-pharmacological interventions for depression are effective for people with TBI. OBJECTIVES To investigate the effectiveness of non-pharmacological interventions for depression in adults and children with TBI at reducing the diagnosis and severity of symptoms of depression. SEARCH METHODS We ran the most recent search on 11 February 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), three other databases and clinical trials registers. Relevant conference proceedings and journals were handsearched, as were the reference lists of identified studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of non-pharmacological interventions for depression in adults and children who had a TBI. DATA COLLECTION AND ANALYSIS Two authors independently selected trials from the search results, then assessed risk of bias and extracted data from the included trials. The authors contacted trial investigators to obtain missing information. We rated the overall quality of the evidence of the primary outcomes using the GRADE approach. MAIN RESULTS Six studies met the inclusion criteria, with a total of 334 adult participants. We identified no studies that included children as participants. All studies were affected by high risk of bias due to a lack of blinding of participants and personnel; five studies were affected by high risk of bias for lack of blinding of outcome assessors. There was high or unclear risk of biases affecting some studies across all the Cochrane risk of bias measures.Three studies compared a psychological intervention (either cognitive behaviour therapy or mindfulness-based cognitive therapy) with a control intervention. Data regarding depression symptom outcome measures were combined in a meta-analysis, but did not find an effect in favour of treatment (SMD -0.14; 95% CI -0.47 to 0.19; Z = 0.83; P = 0.41). The other comparisons comprised of single studies of depression symptoms and compared; cognitive behaviour therapy versus supportive psychotherapy (SMD -0.09; 95% CI -0.65 to 0.48; Z = 0.30; P = 0.77); repetitive transcranial magnetic stimulation plus tricyclic antidepressant (rTMS + TCA) versus tricyclic antidepressant alone (SMD -0.84; 95% CI -1.36 to -0.32; Z = 3;19, P = 0.001); and a supervised exercise program versus exercise as usual (SMD -0.43; 95% CI -0.88 to 0.03; Z = 1.84; P = 0.07). There was very-low quality evidence, small effect sizes and wide variability of results, suggesting that no comparisons showed a reliable effect for any intervention.Only one study mentioned minor, transient adverse events from repetitive transcranial magnetic stimulation. AUTHORS' CONCLUSIONS The review did not find compelling evidence in favour of any intervention. Future studies should focus on participants with a diagnosed TBI and include only participants who have a diagnosis of depression, or who record scores above a clinical cutoff on a depression measure. There is a need for additional RCTs that include a comparison between an intervention and a control that replicates the effect of the attention given to participants during an active treatment.
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Affiliation(s)
- Paul Gertler
- University of SydneyJohn Walsh Centre for Rehabilitation ResearchKolling InstituteSt. LeonardsAustraliaNSW 2065
| | - Robyn L Tate
- University of SydneyJohn Walsh Centre for Rehabilitation ResearchKolling InstituteSt. LeonardsAustraliaNSW 2065
| | - Ian D Cameron
- University of SydneyJohn Walsh Centre for Rehabilitation ResearchKolling InstituteSt. LeonardsAustraliaNSW 2065
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Auger RR, Burgess HJ, Emens JS, Deriy LV, Thomas SM, Sharkey KM. Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2015; 11:1199-236. [PMID: 26414986 DOI: 10.5664/jcsm.5100] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 01/28/2023]
Abstract
A systematic literature review and meta-analyses (where appropriate) were performed and the GRADE approach was used to update the previous American Academy of Sleep Medicine Practice Parameters on the treatment of intrinsic circadian rhythm sleep-wake disorders. Available data allowed for positive endorsement (at a second-tier degree of confidence) of strategically timed melatonin (for the treatment of DSWPD, blind adults with N24SWD, and children/ adolescents with ISWRD and comorbid neurological disorders), and light therapy with or without accompanying behavioral interventions (adults with ASWPD, children/adolescents with DSWPD, and elderly with dementia). Recommendations against the use of melatonin and discrete sleep-promoting medications are provided for demented elderly patients, at a second- and first-tier degree of confidence, respectively. No recommendations were provided for remaining treatments/ populations, due to either insufficient or absent data. Areas where further research is needed are discussed.
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