Bright light treatment decreases depression in institutionalized older adults: a placebo-controlled crossover study

High circadian stimulus lighting therapy for depression: Meta-analysis of clinical trials

Although bright light therapy (BLT) has been widely used in the clinical treatment of depression, the antidepressant effect of BLT is not well understood. Considering the connection between depression and disrupted circadian rhythm, we assumed the model of human circadian phototransduction could be more accurate in evaluating the efficacy of BLT for depression compared to light level and spectrum. A systematic review and meta-analysis were conducted and the CS (circadian stimulus) model was used to quantify the efficacy of lighting in BLT. Articles published up to June 2022 were searched in COCHRANE, EMBASE, MEDLINE, and Web of Science. Randomized clinical trials included articles using high circadian stimulus (H-CS, CS > 0.1) as lighting therapy for people with depressive disorder vs. a control group (CS < 0.1). The treatment effect was estimated by calculating the mean difference (MD) with 95% confidence intervals (CIs). Seven trials involving 258 participants met the inclusion criteria. In this sample size, H-CS lighting was associated with a significant reduction in depressive symptoms (MD = −5.56, 95% CI = −9.22 to −1.90, P = 0.003, I² = 64%). According to the meta-analysis, CS can be employed for the clinical evaluation of BLT for patients with depressive disorder and exposure to H-CS lighting significantly reduced depressive symptoms among adults. A range of CS > 0.57 was obtained, during which different lighting parameter combinations (e.g., light levels, spectra, duration, and light distribution) could achieve better treatment for depression.

Effect of the Physical Environment on Health and Well-Being of Nursing Homes Residents: A Scoping Review

OBJECTIVES

In what way the physical environment of nursing homes (NHs) influences the health and well-being of nursing residents is not well codified. The authors aimed to review scientifically based knowledge on this topic.

DESIGN

A systematic scoping review of research into the effect that physical environment in nursing homes has on residents' health.

SETTING AND PARTICIPANTS

Search for relevant English-language articles in PubMed and the Cochrane database before April 15, 2022. Article selection and data extraction were performed by 2 researchers. Studies were included if conducted on nursing home residents and if they examined associations between components of the physical environment and health outcomes.

MEASURES

The review was performed in accordance with the PRISMA statement.

RESULTS

Of 1347 articles retrieved, 59 met the inclusion criteria-40 observational, 1 survey, and 18 interventional studies, of which 5 were randomized controlled trials. Certain environmental features repeatedly show significant positive effect on resident's health, such as noise reduction, tuning of lighting, natural light, easy access to garden, dining environment, and resident-centered interior renovation. Nursing home size was not found to have a direct relationship to resident health and well-being, although it is related to more than only the physical environment (eg, social environment).

CONCLUSIONS AND IMPLICATIONS

This review provides guidance in selective areas of the physical environment for the design of nursing homes, with potential benefits for the health and well-being of residents.

Placebo response and effect in randomized clinical trials: meta-research with focus on contextual effects

BACKGROUND

Contextual effects (i.e., placebo response) refer to all health changes resulting from administering an apparently inactive treatment. In a randomized clinical trial (RCT), the overall treatment effect (i.e., the post-treatment effect in the intervention group) can be regarded as the true effect of the intervention plus the impact of contextual effects. This meta-research was conducted to examine the average proportion of the overall treatment effect attributable to contextual effects in RCTs across clinical conditions and treatments and explore whether it varies with trial contextual factors.

METHODS

Data was extracted from trials included in the main meta-analysis from the latest update of the Cochrane review on "Placebo interventions for all clinical conditions" (searched from 1966 to March 2008). Only RCTs reported in English having an experimental intervention group, a placebo comparator group, and a no-treatment control group were eligible.

RESULTS

In total, 186 trials (16,655 patients) were included. On average, 54% (0.54, 95%CI 0.46 to 0.64) of the overall treatment effect was attributable to contextual effects. The contextual effects were higher for trials with blinded outcome assessor and concealed allocation. The contextual effects appeared to increase proportional to the placebo effect, lower mean age, and proportion of females.

CONCLUSION

Approximately half of the overall treatment effect in RCTs seems attributable to contextual effects rather than to the specific effect of treatments. As the study did not include all important contextual factors (e.g., patient-provider interaction), the true proportion of contextual effects could differ from the study's results. However, contextual effects should be considered when assessing treatment effects in clinical practice.

TRIAL REGISTRATION

PROSPERO CRD42019130257 . Registered on April 19, 2019.

Impact of sensory interventions on the quality of life of long-term care residents: a scoping review

INTRODUCTION AND PURPOSE

Residents in long-term care exhibit diminishing senses (hearing, sight, taste, smell or touch). The purpose of this study was to examine the available literature on the impact of sensory interventions on the quality of life of residents living in long-term care settings.

METHODS

We conducted a mixed-methods scoping review using Arksey and O'Malley's framework. Seven databases (Medline (Ovid), PubMed (non-Medline-Ovid), CINAHL (EBSCO), Embase (Ovid), Ageline, PsycINFO (Ovid), Cochrane Central Register of Controlled Trials until 1 December 2020) were searched. Two reviewers independently screened the studies for sensory interventions using a two-step process. Eligible studies underwent data extraction and results were synthesised descriptively.

RESULTS

We screened 5551 titles and abstracts. A total of 52 articles met our inclusion criteria. Some interventions involved only one sense: hearing (n=3), sight (n=12), smell (n=4) and touch (n=15). Other interventions involved multiple senses (n=18). We grouped the interventions into 16 categories (music programmes, environmental white noise, bright light interventions, visual stimulations, olfactory stimulations, massages, therapeutic touch, tactile stimulations, physical activity plus night-time programmes, pet therapies, various stimuli interventions, Snoezelen rooms, motor and multisensory based strategies, Namaste care, environmental modifications and expressive touch activities).

CONCLUSION

This preliminary review summarised some of the available sensory interventions that will help inform a series of future systematic reviews on each of the specific interventions. The evidence-based knowledge for sensory interventions will also inform a future audit programme for assessing the presence of sensory interventions in long-term care.

Resetting the Aging Clock: Implications for Managing Age-Related Diseases

Worldwide, individuals are living longer due to medical and scientific advances, increased availability of medical care and changes in public health policies. Consequently, increasing attention has been focused on managing chronic conditions and age-related diseases to ensure healthy aging. The endogenous circadian system regulates molecular, physiological and behavioral rhythms orchestrating functional coordination and processes across tissues and organs. Circadian disruption or desynchronization of circadian oscillators increases disease risk and appears to accelerate aging. Reciprocally, aging weakens circadian function aggravating age-related diseases and pathologies. In this review, we summarize the molecular composition and structural organization of the circadian system in mammals and humans, and evaluate the technological and societal factors contributing to the increasing incidence of circadian disorders. Furthermore, we discuss the adverse effects of circadian dysfunction on aging and longevity and the bidirectional interactions through which aging affects circadian function using examples from mammalian research models and humans. Additionally, we review promising methods for managing healthy aging through behavioral and pharmacological reinforcement of the circadian system. Understanding age-related changes in the circadian clock and minimizing circadian dysfunction may be crucial components to promote healthy aging.

Sleep and major depressive disorder: a review of non-pharmacological chronotherapeutic treatments for unipolar depression

Depression is a significant public health issue, made worse by the absence of response to antidepressant medications by many patients. Given the high degree of overlap between sleep and circadian complaints and depression, chronotherapies are a promising avenue for novel, effective, and fast-acting treatments for depression. A critical literature review was conducted of bright light therapy (BLT) as a treatment for unipolar depression. Additionally, a separate critical literature review was also conducted of several promising, non-pharmacological, combination chronotherapeutic treatments, including BLT, sleep deprivation/wake therapy, and sleep phase advance. Results of BLT as a treatment for depression are encouraging, especially when used as an adjunct to antidepressant medications. It may also be desirable in special populations, such as geriatric and perinatal patients. Overall, results from combination chronotherapies are encouraging, though none has strong empirical support. Combining chronotherapies is an avenue of treatment which should be further explored.

Impact of a nurse-led sleep programme on the sleep quality and depressive symptomatology among older adults in nursing homes: A non-randomised controlled study

BACKGROUND

Sleep problems are much more prevalent in nursing home residents than in their community-dwelling counterparts. Cognitive behavioural therapy is likely to improve sleep quality in older adults. However, these interventions have a narrow scope to generalise to nursing home practice, and there are minimal data on the effectiveness of the integration of cognitive behavioural therapy and motivational interviewing in nursing home settings.

AIM

The purpose of this study was to investigate the impact of a nurse-led sleep programme on the sleep quality and depressive symptomatology in cognitively intact nursing home residents.

METHODS

A non-randomised controlled study design was applied to 52 older adults living in three different nursing homes in the same locality. Then, we categorised our study cohort into the following two groups: intervention group in which the older adults received the nurse-led sleep programme and control group in which the older adults received regular nursing home services. One nursing home was assigned to the intervention, and two were assigned to control. The intervention group participated in four weekly 1-hr sessions performed by the first author.

RESULTS

Follow-up assessments conducted at 8 and 12 weeks after the intervention ended revealed that participants in the intervention group experienced a significant improvement in some objective sleep parameters, including awakenings, total wake time, wake after sleep onset and sleep efficiency, as well as a significant decrease in depressive symptomatology.

CONCLUSION

To summarise, the results of this study showed that the nurse-led sleep programme improved the sleep quality and reduced depressive symptomatology in cognitively intact nursing home residents. In this context, we can assert that interventions for sleep problems should be individualised by addressing sleep experience and sleep management strategies of older adults living in nursing homes and should be integrated with motivational interviewing techniques.

Efficacy of light therapy on nonseasonal depression among elderly adults: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to examine the effectiveness of light therapy in the treatment of geriatric depression.

METHODS

A systematic review and meta-analysis were carried out. Data sources for the literature search were PubMed, Cochrane Collaboration's Central Register of Controlled Clinical Trials, Cochrane Systematic Reviews, and ClinicalTrials.gov. Controlled trials of light therapy on older patients with nonseasonal depression and depression rating scales were eligible. Studies were pooled using a random-effect model for comparisons with light therapy. We used effect size (ES), which expresses changes in depression severity, in each selected meta-analysis to calculate the standardized mean difference on the basis of Hedges' adjusted g; positive values indicated that the depression severity improved after light therapy. All results were presented with 95% CIs. Statistical heterogeneity was explored through visual inspection of funnel plots and the I2 statistic. Moderators of effects were explored using meta-regression.

RESULTS

We identified eight trials involving 395 participants that met the inclusion criteria. Light therapy was significantly more effective than comparative treatments, including placebo or dim light, with an ES of 0.422 (95% CI: 0.174-0.709, P=0.001). In addition, six of the eight trials used bright (white) light, resulting in significantly reduced severity of geriatric depression (N=273, ES: 0.460, 95% CI: 0.085-0.836, P=0.016). Furthermore, pale blue light therapy reduced the severity of geriatric depression (N=89, ES: 0.464, 95% CI: 0.046-0.882, P=0.030).

CONCLUSION

Our results highlighted the significant efficacy of light therapy in the treatment of geriatric depression. Additional well-designed, controlled studies are necessary to adopt standard parameters, adequate group sizes, and randomized assignment to evaluate more thoroughly the efficacy of light therapy for treating geriatric depression.

A sham-controlled randomized trial of adjunctive light therapy for non-seasonal depression

BACKGROUND

The aim of the study was to examine the efficacy and safety of morning bright light therapy (BLT) in the treatment of patients with a current major depressive episode (MDE) in bipolar and unipolar disorder without a seasonal pattern. It was a randomized, sham-controlled trial.

METHODS

Adults, ages 18-70 years were randomized to treatment either with BLT or a sham negative ion generator (as a placebo control). The subjects were required to be on a stable and therapeutic dose of psychotropic medication for at least 4 weeks prior to enrollment and their treatment had to be insufficiently effective. Their clinical state was monitored at the baseline and at the end of treatment. The Hamilton Depression Rating Scale-21 items (HDRS-21), Montgomery-Asberg Depression Rating Scale (MADRS), Beck Depression Inventory (BDI-II), Clinical Global Impression-Severity (CGI-S) and Patient Global Impression (PGI) were used. The results were analyzed with an intention-to-treat (ITT) analysis.

RESULTS

Ninety-five patients were enrolled (50 diagnosed with bipolar disorder and 45 with unipolar depression). Fifty-two patients were randomized to treatment with BLT and forty-three were in the placebo group (ITT population). Eighty-three subjects completed the study. There were 12 dropouts (5 in the light group and 7 in the placebo group). After 14 days of treatment, a significant improvement was found in all groups (p<0.001). The subjects treated with BLT did not significantly differ in terms of improvement in HDRS-21 scores at the endpoint when compared to patients treated with placebo (p=0.2). However, further analysis demonstrated significantly higher response (50% v. 27.9%, p=0.02) and remission rates (28.8% v. 11.6%, p=0.04) among patients treated with morning BLT when compared to placebo group. It should be noted that in the population of drug-resistant patients, BLT was more efficacious than placebo. There were no statistically significant differences between unipolar and bipolar disorders (p=0.4).

CONCLUSION

Although overall improvement in HDRS-21 scores were not superior in the BLT group, both response and remission rates were significantly higher among patients treated with BLT relative to those receiving the sham intervention. BLT was also more efficacious than placebo in the population of patients with drug-resistant depression. Further studies to define the subpopulation of patients with non-seasonal depression who may benefit the most from BLT are needed.

Light therapy for non-seasonal depression: systematic review and meta-analysis

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.

Seasonal and meteorological associations with depressive symptoms in older adults: A geo-epidemiological study

BACKGROUND

Given increased social and physiological vulnerabilities, older adults may be particularly susceptible to environmental influences on mood. Whereas the impact of season on mood is well described for adults, studies rarely extend to elders or include objective weather data. We investigated the impact of seasonality and meteorological factors on risk of current depressive symptoms in older adults.

METHODS

We used data on 8027 participants from the first wave of The Irish Longitudinal Study of Ageing, a population-representative cohort of adults aged 50+. Depressive symptoms were recorded using the Centre for Epidemiological Studies Depression Scale. Season was defined according to the World Meteorological Organisation. Data on climate over the preceding thirty years, and temperature and rain over the preceding month, were provided by the Irish Meteorological Service and linked using Geographic Information Systems techniques to participant's geo-coded locations at a resolution of one kilometre.

RESULTS

The highest levels of depressive symptoms were reported in winter and the lowest in spring (mean 6.56 [CI95% 6.09, 7.04] vs. 5.81 [CI95%: 5.40, 6.22]). In fully adjusted linear regression models, participants living in areas with higher levels of rainfall in the preceding and/or current calendar month had greater depressive symptoms (0.04 SE 0.02; p=0.039 per 10mm additional rainfall per month) while those living in areas with sunnier climates had fewer depressive symptoms (-2.67 SE 0.88; p=0.003 for every additional hour of average annual daily sunshine).

LIMITATIONS

This was a cross-sectional analysis thus causality cannot be inferred; monthly rain and temperature averages were available only on a calendar month basis while monthly local levels of sunshine data were not available.

CONCLUSIONS

Environmental cues may influence mood in older adults and thus have relevance for the recognition and treatment of depression in this age group.

Seasonality of depression referrals in older people

Seasonal affective disorder is becoming more widely recognised as a prevalent mood disorder in the adult population. However, few studies have investigated the link between sunlight exposure and mood in the elderly. Referrals to the community Mental Health Care for Older People (MHCOP) in the Hackney and City area, were screened for the number of patients referred with depression in three separate years (2007, 2009 and 2011) in order to determine whether more referrals were made to the service during darker months of the year (October to March) than in the lighter months of the year (April to September). When data from the three years was combined, we found no significant increase in the number of referrals to the MHCOP in the darker months (Chi squared value 1.375, p value (2 tailed) 0.2409). We observed no statistically significant seasonal pattern of referrals, this suggests that depression in older people is not more prevalent in darker months of the year.

Depressive symptoms and circadian activity rhythm disturbances in community-dwelling older women

OBJECTIVES

Aging is associated with changes in circadian rhythms. Current evidence supports a role for circadian rhythms in the pathophysiology of depression. However, little is known about the relationship between depressive symptoms and circadian activity rhythms in older adults. We examined this association in community-dwelling older women.

METHODS

We performed a cross-sectional analysis of 3,020 women (mean age: 83.55 ± 3.79 years) enrolled in the Study of Osteoporotic Fractures. Depressive symptoms were assessed with the Geriatric Depression Scale categorizing participants as "normal" (0-2; referent group, N = 1,961), "some depressive symptoms" (3-5, N = 704), or "depressed" (≥6, N = 355). Circadian activity rhythm variables were measured using wrist actigraphy.

RESULTS

In age-adjusted and Study of Osteoporotic Fractures site-adjusted models, greater levels of depressive symptoms were associated with decreased amplitude (height; df = 3,014, t = -11.31, p for linear trend <0.001), pseudo F-statistic (robustness; df = 3,014, t = -8.07, p for linear trend <0.001), and mesor (mean modeled activity; df = 3014, t = -10.36, p for linear trend <0.001) of circadian activity rhythms. Greater levels of depressive symptoms were also associated with increased odds of being in the lowest quartile for amplitude (df = 1, χ(2) = 9240, p for linear trend <0.001), pseudo F-statistic (df = 1, χ(2) = 49.73, p for linear trend <0.001), and mesor (df = 1, χ(2) = 81.12, p for linear trend <0.001). These associations remained significant in multivariate models. Post-hoc analyses comparing mean amplitude, mesor, and pseudo F-statistic values pair-wise between depression-level groups revealed significant differences between women with "some depressive symptoms" and the "normal" group.

CONCLUSION

These data suggest a graded association between greater levels of depressive symptoms and more desynchronization of circadian activity rhythms in community-dwelling older women. This association was observed even for women endorsing subthreshold levels of depressive symptoms.

Testing a theory-based mobility monitoring protocol using in-home sensors: a feasibility study

Mobility is a key factor in the performance of many everyday tasks required for independent living as a person ages. The purpose of this mixed-methods study was to test a theory-based mobility monitoring protocol by comparing sensor-based measures to self-report measures of mobility and assess the acceptability of in-home sensors with older adults. Standardized instruments to measure physical, psychosocial, and cognitive parameters were administered to 8 community-dwelling older adults at baseline, 3-month, and 6-month visits. Semi-structured interviews to characterize acceptability of the technology were conducted at the 3-month and 6-month visits. Technical issues prevented comparison of sensor-based measures with self-report measures. In-home sensor technology for monitoring mobility is acceptable to older adults. Implementing our theory-based mobility monitoring protocol in a field study in the homes of older adults is a feasible undertaking but requires more robust technology for sensor-based measure validation.

A systematic mapping review of randomized controlled trials (RCTs) in care homes

Background

A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.

Methods

A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.

Results

3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.

Conclusions

This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

Body mass index and 25 hydroxyvitamin D status in patients with and without heart failure

The purpose of this pilot study was to assess the association between 25-hydroxyvitamin D (25[OH]D) concentrations, vitamin D intake, and sunlight exposure in patients with heart failure (HF) compared with healthy volunteers. Fourteen healthy volunteers 50 and older were recruited to compare with 14 patients with HF. Healthy volunteers were compared with HF patients by serum 25(OH)D concentrations, dietary vitamin D intake, weekly sunlight exposure, and other covariates. Independent sample t tests and linear regression models were used to compare differences between healthy volunteers and patients with HF. The mean serum 25(OH)D concentration was not significantly different between groups (healthy volunteers 25.7 ± 11.1 ng/mL, patients with HF 20.4 ± 10.2 ng/mL; P=.2) and no group effect was found in any multivariable models. Body mass index regardless of group was found to be inversely associated with serum 25(OH)D concentrations (P=.025). There was no difference in the dietary intake of vitamin D or calcium between groups. The healthy volunteers had a significantly greater amount of sunlight exposure but this did not result in higher 25(OH)D when compared with those with HF. Our findings suggest that body mass index has an important relationship with 25(OH)D concentrations regardless of a person being healthy or having HF.

Extraskeletal effects of vitamin D in older adults: cardiovascular disease, mortality, mood, and cognition

BACKGROUND

Vitamin D insufficiency is prevalent among older adults and may be associated with higher risk for cardiovascular (CV) disease, mortality, depression, and cognitive deficits.

OBJECTIVE

The aim of this article was to review published observational and experimental studies that explored the association between vitamin D insufficiency and CV disease, mortality, mood, and cognition with an emphasis on older adults.

METHODS

PubMed and Web of Science databases were searched for English-language articles from January 1966 through June 2009 relating to vitamin D, using the following MeSH terms: aged, vitamin D deficiency, physiopathology, drug therapy, cardiovascular diseases, blood pressure, mortality, delirium, dementia, cognitive disorders, depression, depressive disorder, seasonal affective disorder, mental disorders, and vitamin D/therapeutic use. Publications had to include patients > or =65 years of age who had > or =1 recorded measurement of 25-hydroxyvitamin D (25[OH]D) or were receiving vitamin D supplementation. All case-control, cohort, and randomized studies were reviewed.

RESULTS

Forty-two case-control, cohort, and randomized trials were identified and included in the review. Based on these publications, the prevalence of vitamin D insufficiency (25[OH]D concentration <30 ng/mL) in communitydwelling older adults (> or =65 years of age) ranged from 40% to 100%. Epidemiologic data and several small randomized trials found a potential association between vitamin D deficiency (25[OH]D concentration <10 ng/mL) and CV disease, including hypertension and ischemic heart disease. Although subgroup analyses of data from the Women's Health Initiative Randomized Trial (the largest randomized, placebo-controlled trial of vitamin D plus calcium therapy) did not find reductions in blood pressure, myocardial infarction, or CV disease-related deaths, intervention contamination limited the findings. Observational studies and a meta-analysis of randomized controlled trials found a mortality benefit associated with higher serum 25(OH)D concentrations or vitamin D(2) or D(3) supplementation (mean dose, 528 IU/d). Observational and small randomized trials found a potential benefit of sunlight or vitamin D on symptoms of depression and cognition, but the findings were limited by methodologic problems.

CONCLUSIONS

Vitamin D insufficiency appears to be highly prevalent among older adults. Evidence from epidemiologic studies and small clinical trials suggests an association between 25(OH)D concentrations and systolic blood pressure, risk for CV disease-related deaths, symptoms of depression, cognitive deficits, and mortality. The Women's Health Initiative Randomized Trial did not find a benefit of vitamin D supplementation on blood pressure, myocardial infarction, or mortality in postmenopausal women.

Complementary and alternative medicine for the treatment of depressive disorders in women

Complementary and alternative medicine (CAM) therapies are commonly practiced in the United States and are used more frequently among women than men. This article reviews several CAM treatments for depressive disorders in women, with a focus on major depressive disorder across the reproductive life cycle. The CAM therapies selected for this review (ie, S-adenosylmethionine, omega-3 fatty acids, St John's wort, bright light therapy, acupuncture, and exercise) were based on their prevalence of use and the availability of randomized, placebo-controlled data. Further study is necessary to delineate the role of specific CAM therapies in premenstrual syndrome, premenstrual dysphoric disorder, antepartum and postpartum depression, lactation, and the menopausal transition.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to substantially improve patient-reported and observer-reported outcomes in many clinical conditions, but most reports on effects of placebos are based on studies that have not randomised patients to placebo or no treatment. Two previous versions of this review from 2001 and 2004 found that placebo interventions in general did not have clinically important effects, but that there were possible beneficial effects on patient-reported outcomes, especially pain. Since then several relevant trials have been published.

OBJECTIVES

Our primary aims were to assess the effect of placebo interventions in general across all clinical conditions, and to investigate the effects of placebo interventions on specific clinical conditions. Our secondary aims were to assess whether the effect of placebo treatments differed for patient-reported and observer-reported outcomes, and to explore other reasons for variations in effect.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 4, 2007), MEDLINE (1966 to March 2008), EMBASE (1980 to March 2008), PsycINFO (1887 to March 2008) and Biological Abstracts (1986 to March 2008). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Trials with binary data were summarised using relative risk (a value of less than 1 indicates a beneficial effect of placebo), and trials with continuous outcomes were summarised using standardised mean difference (a negative value indicates a beneficial effect of placebo).

MAIN RESULTS

Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I(2) 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I(2) 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

AUTHORS' CONCLUSIONS

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Risk factors and intervention programs for depression in nursing home residents: nursing home staff interview findings

The in-depth qualitative interviews with 25 nursing home staff members were done to examine (a) their perceptions and experiences of risk factors for residents' depression, (b) current depression intervention programs, and (c) specific needs for staff training. The interviewees identified the residents' sense of loss and grief and feelings of isolation and loneliness as the causes of their depression and in-house activities and contract mental health services as current services aimed at reducing depression. They also pointed out the following barriers to providing effective depression interventions: too much dependence on antidepressant medication, low Medicaid reimbursement rate, staff shortage, residents' attitudes, and nursing home culture. The types of training that the staff members desired were: skills to monitor nonverbal signs and changes and to systematically screen different types of depression; education about antidepressants and their effects, side effects, and interaction effects with other medication; and systematic training in different types of psychosocial and behavioral interventions for late-life depression in residents with various levels of physical disabilities and cognitive impairments.

Self-worth therapy for depressive symptoms in older nursing home residents

AIM

The aim of this study is to report the effects of self-worth therapy on depressive symptoms of older nursing home residents.

BACKGROUND

Depression in older people has become a serious healthcare issue worldwide. Pharmacological and non-pharmacological therapies have been shown to have inconsistent effects, and drug treatment can have important side-effects.

METHOD

A quasi-experimental design was used. Older people were sampled by convenience from residents of a nursing home in northern Taiwan between 2005 and 2006. To be included in the study participants had to: (i) have no severe cognitive deficits; (ii) test positive for depressive status and (iii) take the same anti-depressant medication in the previous 3 months and throughout the study. Participants in the experimental group (n = 31) received 30 minutes of one-to-one self-worth therapy on 1 day a week for 4 weeks. Control group participants (n = 32) received no therapy, but were individually visited by the same research assistant, who chatted with them for 30 minutes on 1 day/week for 4 weeks. Depressive status, cognitive status and functional status were measured at baseline, immediately after the intervention and 2 months later. Data were analysed by mean, standard deviations, t-test, chi-squared test and univariate anova.

FINDINGS

Self-worth therapy immediately decreased depressive symptoms relative to baseline, but not relative to control treatment. However, 2 months later, depressive symptoms were statistically significantly reduced relative to control.

CONCLUSION

Self-worth therapy is an easily-administered, effective, non-pharmacological treatment with potential for decreasing depressive symptoms in older nursing home residents.

Spontaneous improvement in randomised clinical trials: meta-analysis of three-armed trials comparing no treatment, placebo and active intervention

BACKGROUND

It can be challenging for patients and clinicians to properly interpret a change in the clinical condition after a treatment has been given. It is not known to which extent spontaneous improvement, effect of placebo and effect of active interventions contribute to the observed change from baseline, and we aimed at quantifying these contributions.

METHODS

Systematic review and meta-analysis, based on a Cochrane review of the effect of placebo interventions for all clinical conditions. We selected all trials that had randomised the patients to three arms: no treatment, placebo and active intervention, and that had used an outcome that was measured on a continuous scale or on a ranking scale. Clinical conditions that had been studied in less than three trials were excluded.

RESULTS

We analysed 37 trials (2900 patients) that covered 8 clinical conditions. The active interventions were psychological in 17 trials, physical in 15 trials, and pharmacological in 5 trials. Overall, across all conditions and interventions, there was a statistically significant change from baseline in all three arms. The standardized mean difference (SMD) for change from baseline was -0.24 (95% confidence interval -0.36 to -0.12) for no treatment, -0.44 (-0.61 to -0.28) for placebo, and -1.01 (-1.16 to -0.86) for active treatment. Thus, on average, the relative contributions of spontaneous improvement and of placebo to that of the active interventions were 24% and 20%, respectively, but with some uncertainty, as indicated by the confidence intervals for the three SMDs. The conditions that had the most pronounced spontaneous improvement were nausea (45%), smoking (40%), depression (35%), phobia (34%) and acute pain (25%).

CONCLUSION

Spontaneous improvement and effect of placebo contributed importantly to the observed treatment effect in actively treated patients, but the relative importance of these factors differed according to clinical condition and intervention.

Complementary and alternative medicine for perinatal depression

INTRODUCTION

Perinatal Major Depressive Disorder (MDD) is common and poses particular treatment dilemmas. Complementary and Alternative Medicine (CAM) treatments are widely used, accessible, and understudied for well-defined psychiatric indications. Women are more likely than men to both suffer from MDD and use CAM.

METHODS

A PubMed/Medline search was conducted to assess the evidence base for commonly utilized CAM treatments, MDD, and perinatal depression.

RESULTS

Among CAM treatments, omega-3 fatty acids have received the most specific study in terms of epidemiological, preclinical, and clinical research for perinatal depression. Three randomized placebo-controlled trials have been conducted in which investigators assessed omega-3 fatty acids vs. placebo for perinatal depression, with conflicting results. CAM interventions that can be easily added to a treatment plan with little risk and general health benefits for most women include omega-3 fatty acids, exercise, and folate, although data are insufficient at this time to recommend any of these as monotherapy for perinatal depression. S-adenosyl-methionine (SAMe) and bright light therapy may be reasonable to consider based on the evidence in MDD. St. John's Wort requires further study with regard to safety in pregnancy, and drug interactions can be a potential problem.

DISCUSSION

Further study is required to elucidate the role of CAM treatments for perinatal depression, and the clinical context of perinatal depression requires safe, effective, and accessible treatment options.

Circadian rhythm disturbances in depression

OBJECTIVE

The aim of this article is to review progress in understanding the mechanisms that underlie circadian and sleep rhythms, and their role in the pathogenesis and treatment of depression.

METHODS

Literature was selected principally by Medline searches, and additional reports were identified based on ongoing research activities in the authors' laboratory.

RESULTS

Many physiological processes show circadian rhythms of activity. Sleep and waking are the most obvious circadian rhythms in mammals. There is considerable evidence that circadian and sleep disturbances are important in the pathophysiology of mood disorders. Depressed patients often show altered circadian rhythms, sleep disturbances, and diurnal mood variation. Chronotherapies, including bright light exposure, sleep deprivation, and social rhythm therapies, may be useful adjuncts in non-seasonal and seasonal depression. Antidepressant drugs have marked effects on circadian processes and sleep.

CONCLUSIONS

Recent progress in understanding chronobiological and sleep regulation mechanisms may provide novel insights and avenues into the development of new pharmacological and behavioral treatment strategies for mood disorders.

Bright light in elderly subjects with nonseasonal major depressive disorder: a double blind randomised clinical trial using early morning bright blue light comparing dim red light treatment

BACKGROUND

Depression frequently occurs in the elderly. Its cause is largely unknown, but several studies point to disturbances of biological rhythmicity. In both normal aging, and depression, the functioning of the suprachiasmatic nucleus (SCN) is impaired, as evidenced by an increased prevalence of day-night rhythm perturbations, such as sleeping disorders. Moreover, the inhibitory SCN neurons on the hypothalamus-pituitary adrenocortical axis (HPA-axis) have decreased activity and HPA-activity is enhanced, when compared to non-depressed elderly. Using bright light therapy (BLT) the SCN can be stimulated. In addition, the beneficial effects of BLT on seasonal depression are well accepted. BLT is a potentially safe, nonexpensive and well accepted treatment option. But the current literature on BLT for depression is inconclusive.

METHODS/DESIGN

This study aims to show whether BLT can reduce non-seasonal major depression in elderly patients. Randomized double blind placebo controlled trial in 126 subjects of 60 years and older with a diagnosis of major depressive disorder (MDD, DSM-IV/SCID-I). Subjects are recruited through referrals of psychiatric outpatient clinics and from case finding from databases of general practitioners and old-people homes in the Amsterdam region. After inclusion subjects are randomly allocated to the active (bright blue light) vs. placebo (dim red light) condition using two Philips Bright Light Energy boxes type HF 3304 per subject, from which the light bulbs have been covered with bright blue- or dim red light- permitting filters. Patients will be stratified by use of antidepressants. Prior to treatment a one-week period without light treatment will be used. At three time points several endocrinological, psychophysiological, psychometrically, neuropsychological measures are performed: just before the start of light therapy, after completion of three weeks therapy period, and three weeks thereafter.

DISCUSSION

If BLT reduces nonseasonal depression in elderly patients, then additional lighting may easily be implemented in the homes of patients to serve as add-on treatment to antidepressants or as a stand-alone treatment in elderly depressed patients. In addition, if our data support the role of a dysfunctional biological clock in depressed elderly subjects, such a finding may guide further development of novel chronobiological oriented treatment strategies.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00332670.

Depression in long-term care

OBJECTIVES

To review the diagnosis and treatment of depressive disorders in long-term care settings.

METHODS

A review of the literature on the diagnosis and treatment of depression in long-term care.

RESULTS

Up to 35% of residents in long-term care facilities may experience either major depression or clinically significant depressive symptoms. These symptoms are often not recognized for at least 2 reasons: depression is not the focus of physicians and nursing personnel and depression is frequently comorbid with other problems that are common in long-term care, such as cognitive impairment, medical illness, and functional impairment. Nevertheless, depression, once diagnosed, can be treated effectively in the nursing home setting. The foundation of treatment is pharmacotherapy, yet other therapeutic approaches, such as exercise and psychological therapies may be of value.

CONCLUSION

Depression, although often unrecognized in long-term care, is a treatable condition and deserves the attention of the entire medical and nursing staff.

Advances in the treatment of geriatric depression

Late-life depression is a rather difficult and complicated issue. Although there have been significant advances in our knowledge in this area, a large number of questions still remain unanswered. The aim of this review is a critical presentation of the current evidence for treatment of depression in the elderly. We summarize the evidence for the effectiveness and safety of a range of proposed treatments, including pharmacological, psychological and alternative therapies and lifestyle changes. The treatments with best evidence of effectiveness are antidepressant pharmacotherapy, electroconvulsive therapy, cognitive–behavioral therapy, psychodynamic psychotherapy, reminiscence therapy, problem-solving therapy and exercise. Implications for future research are discussed.

Vitamin D deficiency is associated with low mood and worse cognitive performance in older adults

BACKGROUND

Vitamin D deficiency is common in older adults and has been implicated in psychiatric and neurologic disorders. This study examined the relationship among vitamin D status, cognitive performance, mood, and physical performance in older adults.

METHODS

A cross-sectional group of 80 participants, 40 with mild Alzheimer disease (AD) and 40 nondemented persons, were selected from a longitudinal study of memory and aging. Cognitive function was assessed using the Short Blessed Test (SBT), Mini-Mental State Exam (MMSE), Clinical Dementia Rating (CDR; a higher Sum of Boxes score indicates greater dementia severity), and a factor score from a neuropsychometric battery; mood was assessed using clinician's diagnosis and the depression symptoms inventory. The Physical Performance Test (PPT) was used to measure functional status. Serum 25-hydroxyvitamin D levels were measured for all participants.

RESULTS

The mean vitamin D level in the total sample was 18.58 ng/mL (standard deviation: 7.59); 58% of the participants had abnormally low vitamin D levels defined as less than 20 ng/mL. After adjusting for age, race, gender, and season of vitamin D determination, vitamin D deficiency was associated with presence of an active mood disorder (odds ratio: 11.69, 95% confidence interval: 2.04-66.86; Wald chi(2) = 7.66, df = 2, p = 0.022). Using the same covariates in a linear regression model, vitamin D deficiency was associated with worse performance on the SBT (F = 5.22, df = [2, 77], p = 0.044) and higher CDR Sum of Box scores (F = 3.20, df = [2, 77], p = 0.047) in the vitamin D-deficient group. There was no difference in performance on the MMSE, PPT, or factor scores between the vitamin D groups.

CONCLUSIONS

In a cross-section of older adults, vitamin D deficiency was associated with low mood and with impairment on two of four measures of cognitive performance.

Self-care management and risk factors for depressive symptoms among elderly nursing home residents in Taiwan

The purpose of this study was to explore self-care management strategies and risk factors for depressive symptoms among elderly residents of nursing homes in Taiwan. Stratified random sampling was used to recruit participants (n = 220). In these elderly nursing home residents, the prevalence of depressive tendency was 55.0%. Although only 42% of participants used self-care strategies to manage depressive symptoms, the most frequently used strategy was "take a walk." Self-learning was the main information source for self-care strategies. Logistic regression analysis indicated that satisfaction with living situation and perceived health status significantly predicted depressive symptoms. Since elders tended to engage in activities and interact with others to manage their depressive symptoms, health care providers in nursing homes should consider improving access to activities and interpersonal contacts for elderly residents. Elders' awareness of strategies to self-manage depressive symptoms also needs to be increased. The risk factors for depressive symptoms may be addressed by providing a pleasant and comfortable living environment, discouraging poor perceived health status, and promoting the health of elderly residents of nursing homes in Taiwan.

Prevalence of insomnia and its associated factors in elderly long-term care residents

Insomnia is a significant problem that may jeopardize elderly residents' quality of life in long-term care settings. However, there are only a few studies dealing with sleeping disturbances among nursing home residents. The goal of this study was to determine the prevalence of insomnia and its associated factors in nursing home residents. A cross-sectional study (n=2332) was conducted among seniors living in long-term care facilities. The findings indicate that 144 (6.2%) participants had an insomnia disorder according to DSM-IV criteria, 17% displayed at least one symptom of insomnia, and more that half of the subjects were benzodiazepine users. According to multivariate analysis, psychological distress (adjusted odds ratio=1.51) and disruptive behaviors (adjusted odds ratio=2.10) were the only factors associated with an insomnia disorder among this population. In conclusion, insomnia is a fairly important problem, as a symptom or a syndrome, among elderly people and deserves attention from caregivers. Alternative interventions to benzodiazepine drugs, which are suited to long-term care residents while tailored to these specific care settings, should be developed.

Bright light treatment of depression for older adults [ISRCTN55452501]

BACKGROUND

The incidence of insomnia and depression in the elder population is significant. It is hoped that use of light treatment for this group could provide safe, economic, and effective rapid recovery.

METHODS

In this home-based trial we treated depressed elderly subjects with bright white (8,500 Lux) and dim red (<10 Lux) light for one hour a day at three different times (morning, mid-wake and evening). A placebo response washout was used for the first week. Wake treatment was conducted prior to the initiation of treatment, to explore antidepressant response and the interaction with light treatment. Urine and saliva samples were collected during a 24-hour period both before and after treatment and assayed for aMT6s and melatonin respectively to observe any change in circadian timing. Subjects wore a wrist monitor to record light exposure and wrist activity. Daily log sheets and weekly mood (GDS) and physical symptom (SAFTEE) scales were administered. Each subject was given a SCID interview and each completed a mood questionnaire (SIGH-SAD-SR) before and after treatment. Also, Hamilton Depression Rating (SIGH-SAD version) interviews were conducted by a researcher who was blind to the treatment condition. A control group of healthy, age-matched, volunteers was studied for one day to obtain baseline data for comparison of actigraphy and hormone levels.

RESULTS

Eighty-one volunteers, between 60 and 79 years old, completed the study. Both treatment and placebo groups experienced mood improvement. Average GDS scores improved 5 points, the Hamilton Depression Rating Scale (HDRS) 17 scores (extracted from the self-rated SIGH-SAD-SR) improved 6 points. There were no significant treatment effects or time-by-treatment interactions. No significant adverse reactions were observed in either treatment group. The assays of urine and saliva showed no significant differences between the treatment and placebo groups. The healthy control group was active earlier and slept earlier but received less light than the depressed group at baseline.

CONCLUSION

Antidepressant response to bright light treatment in this age group was not statistically superior to placebo. Both treatment and placebo groups experienced a clinically significant overall improvement of 16%.

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.

Effectiveness of treatments for depression in older people

OBJECTIVE

To conduct a systematic review of the evidence for the effectiveness of a range of possible treatments for depression in older people.

DATA SOURCES

Literature search using the PubMed, PsycInfo and Cochrane Library databases.

DATA SYNTHESIS

Treatments that have been suggested to be effective for depression were grouped under three categories: medical treatments, psychological treatments, and lifestyle changes/alternative treatments. We describe each treatment, review the studies of its effectiveness in people aged > or = 60 years, and give a rating of the level of evidence.

CONCLUSIONS

The treatments with the best evidence of effectiveness are antidepressants, electroconvulsive therapy, cognitive behaviour therapy, psychodynamic psychotherapy, reminiscence therapy, problem-solving therapy, bibliotherapy (for mild to moderate depression) and exercise. There is limited evidence to support the effectiveness of transcranial magnetic stimulation, dialectical behaviour therapy, interpersonal therapy, light therapy (for people in nursing homes or hospitals), St John's wort and folate in reducing depressive symptoms.

Is the placebo powerless? Update of a systematic review with 52 new randomized trials comparing placebo with no treatment

BACKGROUND

It is widely believed that placebo interventions induce powerful effects. We could not confirm this in a systematic review of 114 randomized trials that compared placebo-treated with untreated patients.

AIM

To study whether a new sample of trials would reproduce our earlier findings, and to update the review.

METHODS

Systematic review of trials that were published since our last search (or not previously identified), and of all available trials.

RESULTS

Data was available in 42 out of 52 new trials (3212 patients). The results were similar to our previous findings. The updated review summarizes data from 156 trials (11 737 patients). We found no statistically significant pooled effect in 38 trials with binary outcomes, relative risk 0.95 (95% confidence interval 0.89-1.01). The effect on continuous outcomes decreased with increasing sample size, and there was considerable variation in effect also between large trials; the effect estimates should therefore be interpreted cautiously. If this bias is disregarded, the pooled standardized mean difference in 118 trials with continuous outcomes was -0.24 (-0.31 to -0.17). For trials with patient-reported outcomes the effect was -0.30 (-0.38 to -0.21), but only -0.10 (-0.20 to 0.01) for trials with observer-reported outcomes. Of 10 clinical conditions investigated in three trials or more, placebo had a statistically significant pooled effect only on pain or phobia on continuous scales.

CONCLUSION

We found no evidence of a generally large effect of placebo interventions. A possible small effect on patient-reported continuous outcomes, especially pain, could not be clearly distinguished from bias.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to improve patient-reported and observer-reported outcomes, but this belief is not based on evidence from randomised trials that compare placebo with no treatment.

OBJECTIVES

To assess the effect of placebo interventions.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2002), MEDLINE (1966 to 2002), EMBASE (1980 to 2002), Biological Abstracts (1986 to 2002), and PsycLIT (1887 to 2002). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Outcome data were available in 156 out of 182 included trials, investigating 46 clinical conditions. We found no statistically significant pooled effect of placebo in 38 studies with binary outcomes (4284 patients), relative risk 0.95 (95% confidence interval (CI) 0.89 to 1.01). The pooled relative risk for patient-reported outcomes was 0.95 (95% CI 0.88 to 1.03) and for observer-reported outcomes 0.91 (95% CI 0.81 to 1.03). There was heterogeneity (P=0.01) but the funnel plot was symmetrical. There was no statistically significant effect of placebo interventions in the four clinical conditions investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. We found an overall effect of placebo treatments in 118 trials with continuous outcomes (7453 patients), standardised mean difference (SMD) -0.24 (95% CI -0.31 to -0.17). The SMD for patient-reported outcomes was -0.30 (95% CI -0.38 to -0.21), whereas no statistically significant effect was found for observer-reported outcomes, SMD -0.10 (95% CI -0.20 to -0.01). There was heterogeneity (P<0.001) and large variability in funnel plot results even for big trials. There was an apparent effect of placebo interventions on pain (SMD -0.25 (95% CI -0.35 to-0.16)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)); but also a substantial risk of bias. There was no statistically significant effect of placebo interventions in eight other clinical conditions investigated in three trials or more: nausea, smoking, depression, overweight, asthma, hypertension, insomnia and anxiety, but confidence intervals were wide.

REVIEWERS' CONCLUSIONS

There was no evidence that placebo interventions in general have clinically important effects. A possible small effect on continuous patient-reported outcomes, especially pain, could not be clearly distinguished from bias.

Light treatment of mood disorders

In 1981, seven patients with nonseasonal depression were treated with bright white light in 1982, bright artificial light was used to treat a manic-depressive patient with a seasonal mood cycle. In the last 20 years, a plethora of studies have further defined the depressive populations, who are responsive to light treatment; the optimal timing, intensity, spectral frequency, and duration of treatment; its comparison with other pharmacological interventions; predictors of response; side-effect profiles; viable placebo-control conditions; alternative devices and forms of administration; potential mechanisms and anatomical pathways mediating light's physiological effects; and its application to other disorders and subsyndromaI states. These studies have been conducted across multiple countries with surprisingly consistent results. Further work is needed, as highlighted in this review, to clarify the specific mechanism of action in subtypes of depressive disorders and differential age and gender effects. Although the majority of work in this area is relatively new, it behooves the reader to remember that Solomon, almost 3000 years ago, wrote in Ecclesiastes: "Truly the light is sweet and a pleasant thing it is for the eyes to behold the sun" (11:7).

Time Course of Response to Antidepressants in Late-Life Major Depression

In the treatment of depression, there is considerable interest in the time course of response and, in particular, the speed with which individuals recover from depressive episodes. Examination of the time course and speed of response is critical for assessing the usefulness of specific treatments. However, while this issue has received attention in mid-life adult populations, it has received little consideration in the context of late-life major depression. The synthesis of empirical reports indicates that, while older adults with depression seem to respond with the same speed as mid-life adults, several factors have consistently been associated with reduced speed of response to antidepressant treatment, including greater severity of depressive symptoms and co-occurring anxiety symptoms. Limited evidence suggests that sleep impairment and genetic factors (e.g. presence of the s allele of the serotonin transporter gene promoter region) may also be associated with reduced speed of response. Some factors have consistently been found to be unrelated to speed of response (demographic characteristics, nonpsychiatric physical illnesses) whereas other factors have only mixed evidence supporting any effect (psychosocial and other clinical factors). While there is little work available to date, some evidence suggests that time course and speed of response affect longer-term outcomes of depression pharmacotherapy; thus, older adults with more rapid versus slower patterns of response may differ in the types of maintenance treatment needed to avert additional depressive episodes. None of potential strategies for accelerating speed of response have been clearly shown to be effective in late-life depression. Future treatment studies for late-life depression should routinely consider not only overall efficacy of a given pharmacotherapy (i.e. total rate of response), but time course and speed of response. To this end, new investigations must be designed to overcome the methodological limitations of prior studies that have examined time course and they should include a range of potential covariates and outcomes of between-patient differences in speed of response. Better understanding of factors related to such differences may suggest new intervention strategies to accelerate response.

Light therapy for non-seasonal depression

BACKGROUND

Efficacy of light therapy for non-seasonal depression has been studied without any consensus on its efficacy.

OBJECTIVES

To evaluate clinical effects of bright light therapy in comparison to the inactive placebo treatment for non-seasonal depression.

SEARCH STRATEGY

We searched the Depression Anxiety & Neurosis Controlled Trials register (CCDANCTR January 2003), comprising the results of searches of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 -), EMBASE (1980 -), CINAHL (1982 -), LILACS (1982 -), National Research Register, PsycINFO/PsycLIT (1974 -), PSYNDEX (1977 -), and SIGLE (1982 - ) using the group search strategy and the following terms: #30 = phototherapy or ("light therapy" or light-therapy). We also sought trials from conference proceedings and references of included papers, and contacted the first author of each study as well as leading researchers in the field.

SELECTION CRITERIA

Randomized controlled trials comparing bright light with inactive placebo treatments for non-seasonal depression.

DATA COLLECTION AND ANALYSIS

Data were extracted and quality assessment was made independently by two reviewers. The authors were contacted to obtain additional information.

MAIN RESULTS

Twenty studies (49 reports) were included in the review. Most of the studies applied bright light as adjunctive treatment to drug therapy, sleep deprivation, or both. In general, the quality of reporting was poor, and many reviews did not report adverse effects systematically. The treatment response in the bright light group was better than in the control treatment group, but did not reach statistical significance. The result was mainly based on studies of less than 8 days of treatment. The response to bright light was significantly better than to control treatment in high-quality studies (standardized mean difference (SMD) -0.90, 95% confidence interval (CI) -1.50 to -0.31), in studies applying morning light treatment (SMD -0.38, CI -0.62 to -0.14), and in sleep deprivation responders (SMD -1.02, CI -1.60 to -0.45). Hypomania was more common in the bright light group compared to the control treatment group (risk ratio 4.91, CI 1.66 to 14.46, number needed to harm 8, CI 5 to 20). Twenty studies (49 reports) were included in the review. Most of the studies applied bright light as adjunctive treatment to drug therapy, sleep deprivation, or both. Treatment

REVIEWERS' CONCLUSIONS

For patients suffering from non-seasonal depression, bright light therapy offers modest though promising antidepressive efficacy, especially when administered during the first week of treatment, in the morning, and as an adjunctive treatment to sleep deprivation responders. Hypomania as a potential adverse effect needs to be considered. Due to limited data and heterogeneity of studies these results need to be interpreted with caution.

Sleep Dysfunction in Alzheimer's Disease and Other Dementias

Changes in sleep architecture and circadian rhythms, including increased sleep latency and nighttime awakenings, decreased slow-wave sleep, rapid eye movement sleep, and total sleep time, and increased daytime napping are widespread in people with dementia. In addition, cyclic agitation episodes ("sundowning"), nightmares or hallucinations, sleep attacks, and nocturnal behavioral outbursts are associated with specific dementia syndromes. Sleep hygiene recommendations, particularly those aimed at reducing daytime sleep and improving the sleep environment and routine, can offset the circadian disturbances of some dementia patients. However, they can be burdensome for caregivers to implement, and must be targeted to the specific patterns of sleep disturbances patients are experiencing. Pharmacologic treatments may be useful for symptomatic treatment of insomnia and nighttime behavioral disturbances in dementia patients, but there have been few controlled trials demonstrating their efficacy or long-term safety. Clonazepam is highly effective for treating the nighttime behaviors associated with rapid eye movement behavior disorder. For most dementia patients, however, the side effect risks of prolonged use of sedating medications must be weighed against the potential benefits. Dementia patients should be evaluated for common primary sleep disorders that may contribute to nighttime behavioral disturbances and impact treatment decisions. Continuous positive airway pressure, the gold standard for treating obstructive sleep apnea, can be tolerated by mild to moderately demented individuals with support from supervising caregivers. Increased daily light exposure and physical activity may help normalize circadian rest-activity rhythms in some dementia patients, although the frequency and dose needed to maintain treatment effects is currently not known.

Depression in late life: review and commentary

Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.