Use of light therapy in German psychiatric hospitals

Delivery of bright light therapy within the Veterans Health Administration

BACKGROUND

Bright light therapy (BLT) is efficacious for seasonal and non-seasonal depression. However, the current state of BLT use in practice is unknown, impeding efforts to identify and address utilization gaps. This study's objective was to investigate BLT delivery in a nationwide U.S. healthcare system.

METHODS

This was a retrospective observational study of electronic medical records from all veterans who received outpatient mood disorder-related care in the Veterans Health Administration (VHA) from October 2008 through September 2020. BLT delivery was measured through the placement of light box consults.

RESULTS

Of the 3,442,826 veterans who received outpatient mood disorder care, only 57,908 (1.68 %) received a light box consult. Consults increased by 548.44 % (99.9 % credible interval: 467.36 %, 638.74 %) over the timeframe and displayed a robust yearly cycle that peaked on either December 21st or December 22nd. Past mental health treatment for a mood disorder was associated with a higher probability of a consult (relative risk = 4.79, 99.9 % CI: 4.21, 5.60). There was low representation related to veteran age, gender, race, and ethnicity.

LIMITATIONS

No information on patients who declined light boxes or actual light box use following consult placement.

CONCLUSIONS

Outpatient BLT delivery for mood disorders in the VHA remains low, despite significant growth over the past decade. It also displays a strong seasonal rhythm that peaks on the winter solstice, suggesting a limited focus on seasonal depression and a suboptimal reactive approach to changing sunlight. Overall, there exists ample opportunity for novel implementation efforts aimed at increasing utilization of BLT.

Epidemiology and socioeconomic impact of seasonal affective disorder in Austria

BACKGROUND

Seasonal affective disorder (SAD) is a subtype of recurrent depressive or bipolar disorder that is characterized by regular onset and remission of affective episodes at the same time of the year. The aim of the present study was to provide epidemiological data and data on the socioeconomic impact of SAD in the general population of Austria.

METHODS

We conducted a computer-assisted telephone interview in 910 randomly selected subjects (577 females and 333 males) using the Seasonal Health Questionnaire (SHQ), the Seasonal Pattern Assessment Questionnaire (SPAQ), and the Sheehan Disability Scale (SDS). Telephone numbers were randomly drawn from all Austrian telephone books and transformed using the random last digits method. The last birthday method was employed to choose the target person for the interviews.

RESULTS

Out of our subjects, 2.5% fulfilled criteria for the seasonal pattern specifier according to DSM-5 and 2.4% (95% CI=1.4-3.5%) were diagnosed with SAD. When applying the ICD-10 criteria 1.9% (95% CI=0.9-2.8%) fulfilled SAD diagnostic criteria. The prevalence of fall-winter depression according to the Kasper-Rosenthal criteria was determined to be 3.5%. The criteria was fulfilled by 15.1% for subsyndromal SAD (s-SAD). We did not find any statistically significant gender differences in prevalence rates. When using the DSM-5 as a gold standard for the diagnosis of SAD, diagnosis derived from the SPAQ yielded a sensitivity of 31.8% and a specificity of 97.2%. Subjects with SAD had significantly higher scores on the SDS and higher rates of sick leave and days with reduced productivity than healthy subjects.

CONCLUSIONS

Prevalence estimates for SAD with the SHQ are lower than with the SPAQ. Our data are indicative of the substantial burden of disease and the socioeconomic impact of SAD. This epidemiological data shows a lack of gender differences in SAD prevalence. The higher rates of females in clinical SAD samples might, at least in part, be explained by lower help seeking behaviour in males.

The psychiatry of light

Bright light therapy and the broader realm of chronotherapy remain underappreciated and underutilized, despite their empirical support. Efficacy extends beyond seasonal affective disorder and includes nonseasonal depression and sleep disorders, with emerging evidence for a role in treating attention-deficit/hyperactivity disorder, delirium, and dementia. A practical overview is offered, including key aspects of underlying biology, indications for treatment, parameters of treatment, adverse effects, and transformation of our relationship to light and darkness in contemporary life.

Bright light therapy for depression: a review of its effects on chronobiology and the autonomic nervous system

Bright light therapy (BLT) is considered among the first-line treatments for seasonal affective disorder (SAD), yet a growing body of literature supports its use in other neuropsychiatric conditions including non-seasonal depression. Despite evidence of its antidepressant efficacy, clinical use of BLT remains highly variable internationally. In this article, we explore the autonomic effects of BLT and suggest that such effects may play a role in its antidepressant and chronotherapeutic properties. After providing a brief introduction on the clinical application of BLT, we review the chronobiological effects of BLT on depression and on the autonomic nervous system in depressed and non-depressed individuals with an emphasis on non-seasonal depression. Such a theory of autonomic modulation via BLT could serve to integrate aspects of recent work centered on alleviating allostatic load, the polyvagal theory, the neurovisceral integration model and emerging evidence on the roles of glutamate and gamma-hydroxybutyric acid (GABA).

On the application of light therapy in German-speaking countries

Many studies have investigated seasonal affective disorder (SAD; fall-winter-depression) and its treatment with light therapy (LT). However, to the best of our knowledge, no other study has investigated the usage of LT in Europe since 1994. Thus, we performed a survey in hospitals with adult psychiatric departments in German-speaking countries by questionnaire. First, a questionnaire was constructed, considering also recent developments in LT. This questionnaire was sent to all hospitals with adult psychiatric departments listed in the "Deutsches Krankenhaus Adressbuch," which contains hospitals from all German-speaking countries (Germany, Switzerland, and Austria). Non-responders were asked to answer the questionnaire by mail and by phone. We achieved a completion rate of 58%. Data show almost no relevant, non-artificial differences between countries as well as between type of hospital. LT is more frequently used in university and state hospitals than in other types of treatment facilities. Compared to 1994, the major findings are (1) a substantial increase in the use of LT from 13.0 to 69.8% with no differences between Germany, Austria, and Switzerland, (2) this increase is mostly due to treatment for various forms of depression and further possible applications are less often considered, (3) there is a shift in the usage of LT from monotherapy to combination of pharmacotherapy with LT as an adjunctive treatment, and (4) a north-south comparison showed no substantial differences. Considerably higher rates of usage of LT have been found compared to the last survey in German-speaking countries taking place in 1994. Usage almost tripled; however, possible indications for LT other than SAD and non-seasonal depression are not applied to full extent. Further efforts on the propagation of LT should therefore be undertaken, with the same rigorous studies as for pharmacotherapy.

Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects

Bright light therapy for seasonal affective disorder (SAD) has been investigated and applied for over 20 years. Physicians and clinicians are increasingly confident that bright light therapy is a potent, specifically active, nonpharmaceutical treatment modality. Indeed, the domain of light treatment is moving beyond SAD, to nonseasonal depression (unipolar and bipolar), seasonal flare-ups of bulimia nervosa, circadian sleep phase disorders, and more. Light therapy is simple to deliver to outpatients and inpatients alike, although the optimum dosing of light and treatment time of day requires individual adjustment. The side-effect profile is favorable in comparison with medications, although the clinician must remain vigilant about emergent hypomania and autonomic hyperactivation, especially during the first few days of treatment. Importantly, light therapy provides a compatible adjunct to antidepressant medication, which can result in accelerated improvement and fewer residual symptoms.

Treatment indications for light therapy

Light therapy (LT) has become increasingly popular in various countries around the world in the last decade. For instance, according to a recent survey carried out in Germany in 1992, 13% (n = 56) of all German psychiatric hospitals (n = 422) used LT for different treatment indications and another 8% indicated their interest to do so. Among university facilities LT is even more popular, with a percentage of 57%. Although the most frequently used treatment indication for LT is seasonal affective disorder (SAD) or its subsyndromal form (S-SAD) it is apparent that other forms of depression e.g. non-seasonal forms, either acute or chronic are also a target for this new treatment modality. There is a number of studies supporting the use of LT for SAD (for review), however there are just a few studies for non-seasonal depression or for the other treatment indications (for review).