Dawn simulation vs. lightbox treatment in winter depression: a comparative study

Selecting, implementing and evaluating control and placebo conditions in light therapy and light-based interventions

Introduction: Light profoundly influences human physiology, behaviour and cognition by affecting various functions through light-sensitive cells in the retina. Light therapy has proven effective in treating seasonal depression and other disorders. However, designing appropriate control conditions for light-based interventions remains a challenge.Materials and methods: This article presents a novel framework for selecting, implementing and evaluating control conditions in light studies, offering theoretical foundations and practical guidance. It reviews the fundamentals of photoreception and discusses control strategies such as dim light, darkness, different wavelengths, spectral composition and metameric conditions. Special cases like dynamic lighting, simulated dawn and dusk, complex interventions and studies involving blind or visually impaired patients are also considered.Results: The practical guide outlines steps for selection, implementation, evaluation and reporting, emphasizing the importance of α-opic calculations and physiological validation.Conclusion: In conclusion, constructing effective control conditions is crucial for demonstrating the efficacy of light interventions in various research scenarios.

Antidepressant Effect of Blue Light on Depressive Phenotype in Light-Deprived Male Rats

Blue light has been previously reported to play a salient role in the treatment of seasonal affective disorder. The present study aimed to investigate whether blue light had antidepressant effect on light-deprivation-induced depression model, and the underlying visual neural mechanism. Blue light mitigated depression-like behaviors induced by light deprivation as measured by elevated sucrose preference and reduced immobility time. Blue light enhanced melanopsin expression and light responses in the retina. We also found the upregulation of serotonin and brain derived neurotrophic factor expression in the c-fos-positive areas of rats treated with blue light compared with those maintained in darkness. The species gap between nocturnal albino (Sprague-Dawley rat) and diurnal pigmented animals (human) might have influenced extrapolating data to humans. Blue light has antidepressant effect on light-deprived Sprague-Dawley rats, which might be related to activating the serotonergic system and neurotrophic activity via the retinoraphe and retinoamygdala pathways. Blue light is the effective component of light therapy for treatment of depression.

Harnessing the Four Elements for Mental Health

Humans are intimately connected to nature, and our physical and mental health is influenced strongly by our environment. The "elements," classically described in humoral theory as Fire, Water, Earth, and Air, all may impact our mental health. In a contemporary sense, these elements reflect a range of modifiable factors: UV light or heat therapy (Fire); sauna, hydrotherapy, and balneotherapy (Water); nature-based exposure therapy and horticulture (Earth); oxygen-rich/clean air exposure; and breathing techniques (Air). This theoretical scoping review paper details the emerging evidence for a range of these elements, covering epidemiological and interventional data, and provides information on how we can engage in "biophilic" activities to harness their potential benefits. Interventional examples with emerging evidentiary support include "forest-bathing," heat therapy, sauna, light therapy, "greenspace" and "bluespace" exercise, horticulture, clay art therapy activities, and pranayamic yoga breathing exercises. Further robust research is however required to firmly validate many of these interventions, and to establish their therapeutic applications for the benefit of specific mental health disorders.

Light therapy: is it safe for the eyes?

OBJECTIVE

Light therapy has become an increasingly popular treatment for depression and a range of other neuropsychiatric conditions. Yet, concerns have been raised about the ocular safety of light therapy.

METHOD

We conducted the first systematic review into the ocular safety of light therapy. A PubMed search on January 4, 2017, identified 6708 articles, of which 161 were full-text reviewed. In total, 43 articles reporting on ocular complaints and ocular examinations were included in the analyses.

RESULTS

Ocular complaints, including ocular discomfort and vision problems, were reported in about 0% to 45% of the participants of studies involving light therapy. Based on individual studies, no evident relationship between the occurrence of complaints and light therapy dose was found. There was no evidence for ocular damage due to light therapy, with the exception of one case report that documented the development of a maculopathy in a person treated with the photosensitizing antidepressant clomipramine.

CONCLUSION

Results suggest that light therapy is safe for the eyes in physically healthy, unmedicated persons. The ocular safety of light therapy in persons with preexisting ocular abnormalities or increased photosensitivity warrants further study. However, theoretical considerations do not substantiate stringent ocular safety-related contraindications for light therapy.

Seasonal affective disorder, winter type: current insights and treatment options

Seasonal affective disorder (SAD), winter type, is a seasonal pattern of recurrent major depressive episodes most commonly occurring in autumn or winter and remitting in spring/summer. The syndrome has been well-known for more than three decades, with light treatment being the treatment of first choice. In this paper, an overview is presented of the present insights in SAD. Description of the syndrome, etiology, and treatment options are mentioned. Apart from light treatment, medication and psychotherapy are other treatment options. The predictable, repetitive nature of the syndrome makes it possible to discuss preventive treatment options. Furthermore, critical views on the concept of SAD as a distinct diagnosis are discussed.

Chronobiological Therapy for Mood Disorders

Chronobiological therapies for mood disorders include manipulations of the sleep-wake cycle such as sleep deprivation and sleep phase advance and the controlled exposure to light and darkness. Their antidepressant efficacy can overcome drug resistance and targets the core depressive symptoms including suicide, thus making them treatment options to be tried either alone or as adjunctive treatments combined with common psychopharmacological interventions. The specific pattern of mood change observed with chronobiological therapies is characterized by rapid and sustained effects, when used among themselves or combined with drugs. Effects sizes are the same reported for the most effective psychiatric treatments, but side effects are usually marginal or absent. New treatment protocols are developed to adapt them in different clinical settings. This review deals with the general principles of clinical chronobiology and the latest findings in this rapidly developing field.

Dawn simulation vs. bright light in seasonal affective disorder: Treatment effects and subjective preference

BACKGROUND

Studies comparing the efficacy of dawn simulation to conventional bright light for the treatment of seasonal affective disorder (in parallel groups) have yielded conflicting results. This crossover study investigated treatment outcomes and long-term treatment preference.

METHODS

Forty winter depressives were treated for a week with bright light (4.300lx for 30-45min shortly after awakening) or dawn simulation (gradually increasing light during the last 30min of sleep achieving 100lx before alarm beep, with the dawn simulator placed closer to the open eyes for a further 15min: 250lx). The depression level was self-rated using SIGH-SAD-SR.

RESULTS

Depression scores reduced similarly following bright light and dawn simulation: for 43.8% and 42.2% (medians), respectively; efficacy ratio was 23:17. The preference was also similar (21:19). Among those who preferred bright light, the most common reason was that they perceived the bright light to be more effective (19/21; it was more effective, p=0.0096; this subgroup tended to have more severe depression) and ease of use (6/21). Among those who preferred the dawn simulator, the reasons were a more "natural" action (9/19), device compactness and/or time-saving (10/19) and in 4 cases where bright light caused eyestrain.

LIMITATIONS

Not overhead naturalistic light for dawn simulation, self-rating of depression.

CONCLUSIONS

Dawn simulation is similarly effective to bright light in the treatment of winter depression. Patients with more severe depression tended to report greater improvement with bright light; in such cases, this would outweigh the non-clinical advantages of dawn simulation.

Treatment of seasonal affective disorders

Seasonal affective disorder (SAD) is a subform of major depressive disorder, recurrent, or bipolar disorder with a regular onset of depressive episodes at a certain time of year, usually the winter. The treatment of SAD is similar to that of other forms of affective disorder, except that bright light therapy is recommended as the first-line option. Light therapy conventionally involves exposure to visible light of at least 2500 lux intensity at eye level. The effects of light therapy are thought to be mediated exclusively by the eyes, not the skin, although this assumption has not yet been verified. Morning light therapy has proven to be superior to treatment regimens in the evening. Response rates to light therapy are about 80% in selected patient populations, with atypical depressive symptoms being the best predictor of a favorable treatment outcome. Data from randomized, controlled trials suggest that antidepressants are effective in the treatment of SAD. Three double-blind, placebo-controlled trials have been conducted showing promising results for the selective serotonin reuptake inhibitors (SSRIs) sertraline and fluoxetine, as well as for moclobemide, a reversible inhibitor of monoamine oxidase A.

The effects of bright-light therapy on actigraphical measured sleep last for several weeks post-treatment. A study in a nursing home population

We investigated the time-course of nocturnal actigraphic measures, following the termination of bright-light therapy for sleep disturbances in demented nursing home patients. From an earlier study, 11 nursing home patients (86 +/- 9 years, Mini-Mental Status Examination score 12 +/- 4) with actigraphically measured sleep efficiency < 85%, were recruited to morning bright-light treatment (6000-8000 lux) 2 h per day for 14 days. Actigraphic measures were registered at pretreatment, treatment and at four monthly post-treatment periods. Each actigraphic recording period consisted of seven consecutive days. Sleep improved substantially with treatment; sleep efficiency increased from 73% to 86% and total nocturnal wake time was reduced by nearly 2 h. During the 16 weeks post-treatment period, actigraphic measures gradually returned to pretreatment levels. Sleep efficiency remained significantly higher than the pretreatment level 4 weeks after treatment termination. Sleep onset latency remained significantly reduced up until 12 weeks post-treatment. This study supports previous findings of beneficial effects of bright-light therapy for sleep disturbances in demented nursing home patients. Furthermore, these results are the first to suggest that post-treatment effects of short-term bright-light therapy may last longer than previously assumed.

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).

Effect of simulated dawn on quality of sleep--a community-based trial

BACKGROUND

Morning light exposure administered as simulated dawn looks a promising method to treat Seasonal Affective Disorder, but it may moreover help with resetting the inaccurate organisation of body clock functions relative to sleep occurring in winter among people in general. Disturbances in sleep patterns are common and may compromise wellbeing even in the short term. Our hypothesis was that simulated dawn could improve the subjective quality of sleep during winter.

METHODS

A community-based trial with 100 volunteer subjects provided with dawn simulators. Study period lasted for eight weeks, and subjects used the dawn simulators for two weeks at a time, each subject acting as his own control (ABAB-design). Main outcome measure was subjective quality of sleep recorded each morning with Groningen Sleep Quality Scale.

RESULTS

77 subjects completed the trial. Quality of sleep improved while subjects were using dawn simulator-devices (p = 0.001). The treatment became beneficial after six days' use of dawn simulator, but the effect did not last after the use was ceased.

CONCLUSION

Dawn simulation may help to improve the subjective quality of sleep, but the benefits are modest. Further research is needed to verify these findings and to elucidate the mechanism by which dawn simulation acts on the sleep-wake pattern.

Seasonal affective disorder: an overview

Seasonal Affective Disorder (SAD) is a condition of regularly occurring depressions in winter with a remission the following spring or summer. In addition to depressed mood, the patients tend to experience increased appetite and an increased duration of sleep during the winter. SAD is a relatively common condition, affecting 1-3% of adults in temperate climates, and it is more prevalent in women. The pathological mechanisms underlying SAD are incompletely understood. Certain neurotransmitters have been implicated; a dysfunction in the serotonin system in particular has been demonstrated by a variety of approaches. The role of circadian rhythms in SAD needs to be clarified. The phase-delay hypothesis holds that SAD patients' circadian rhythms are delayed relative to the sleep/wake or rest/activity cycle. This hypothesis predicts that the symptoms of SAD will improve if the circadian rhythms can be phase-advanced. There is some experimental support for this. SAD can be treated successfully with light therapy. In classical light therapy, the SAD sufferer sits in front of a light box, exposed to 2000-10,000 lux for 30-120 min daily during the winter. Other forms of light treatments, pharmacotherapy, and other therapies are currently being tested for SAD.

Randomized placebo-controlled trial of donepezil in patients with progressive supranuclear palsy

OBJECTIVE

There is no effective treatment for progressive supranuclear palsy (PSP). Because results of immunochemical and pharmacologic studies suggest that the cholinergic system may play a role in the cognitive and motor features of PSP, the authors investigated the effects of donepezil (10 mg/day), an acetylcholinesterase inhibitor, in 21 patients with PSP (mean age +/- SD; 65.7 +/- 4.7 years) by a randomized, double-blind, placebo-controlled crossover trial.

METHODS

Donepezil and placebo were administered for 6 weeks each with a 1-month washout period. Patients were evaluated before and at the end of each treatment phase. Outcome measures evaluated neuropsychiatric, global cognitive, frontal, memory, motor, and activities of daily living (ADL) status.

RESULTS

Two patients withdrew during the washout phase because of unrelated medical problems. Donepezil-induced systemic side effects were transient and generally mild. Because of worsening of motor function, three patients received 5 mg/day of donepezil. All patients achieved blood and CSF therapeutic levels of donepezil. While the patients were taking donepezil, their Double Memory Test scores improved, whereas their ADL/mobility scores significantly worsened.

CONCLUSION

The findings suggest that acetylcholinesterase inhibitors such as donepezil have at best selective, modest effects on cognition in patients with PSP. In light of its deleterious effects on ADL/mobility, donepezil is not recommended for this patient population.

Dawn simulation and bright light in the treatment of SAD: a controlled study

BACKGROUND

Some small controlled studies have found that dawn simulation is effective in treating seasonal affective disorder (SAD). With a larger sample size and a longer duration of treatment, we compared dawn simulation with bright light therapy and a placebo condition in patients with SAD.

METHOD

Medication-free patients with SAD were randomly assigned to one of three conditions: bright light therapy (10,000 lux for 30 min, from 6:00 AM to 6:30 AM), dawn simulation (1.5 hour dawn signal from 4:30 AM to 6:00 AM peaking at 250 lux), and a placebo condition, a dim red light (1.5 hour dawn signal from 4:30 am to 6:00 AM peaking at 0.5 lux.) Over the subsequent 6 weeks, the subjects were blindly rated by a psychiatrist using the Structured Interview Guide for the Hamilton Depression Rating-Seasonal Affective Disorder Version (SIGH-SAD). We modeled the profiles of the remissions (SIGH-SAD < or = 8) and response (> or =50% decrease in SIGH-SAD) to treatment over time using Cox proportional hazards models.

RESULTS

The sample consisted of 95 subjects who were randomized to the three conditions: bright light (n = 33), dawn simulation (n = 31) and placebo (n = 31). Dawn simulation was associated with greater remission (p <.05) and response (p <.001) rates compared to the placebo. Bright light did not differ significantly from the placebo. Dawn simulation was associated with greater remission (p <.01) and response (p <.001) rates compared to the bright light therapy. The mean daily hours of sunshine during the week before each visit were associated with a significant increase in likelihood of both remission (p <.001) and response (p <.001).

CONCLUSIONS

Dawn simulation was associated with greater remission and response rates compared to the placebo and compared to bright light therapy. The hours of sunshine during the week before each assessment were associated with a positive clinical response.

Can winter depression be prevented by Ginkgo biloba extract? A placebo-controlled trial

OBJECTIVE

The aim was to test the hypothesis that the Ginkgo biloba extract PN246, in tablet form (brand name Bio-Biloba), may prevent the symptoms of winter depression (WD) in patients with seasonal affective disorder (SAD).

METHOD

A total of 27 SAD patients were randomized to receive double-blind placebo or Bio-Biloba for 10 weeks or until they developed symptoms of WD, starting in a symptom-free phase about 1 month before expected WD symptoms. An extended Montgomery-Asberg Depression Rating Scale was completed before and immediately after termination of medication. The patients also self-rated some key symptoms on a visual analogue scale every 2 weeks during the trial.

RESULTS

There were no significant differences between the treatment groups in the number of patients who developed treatment-requiring WD, or in the development of single key symptoms during the trial.

CONCLUSION

We did not find that Ginkgo biloba was able to prevent the development of the symptoms of winter depression.

Direct assessment of improvement in winter depression with a visual analogue scale: high reliability and validity

Reliability and validity of direct visual analogue scale (VAS) ratings of improvement were assessed in 162 patients with Seasonal Affective Disorder, Winter Depression type (W-SAD), after light treatment for 6 consecutive days. The patients were rated with the Montgomery-Asberg Depression Rating Scale (MADRS) and a scale for the 'atypical' symptoms hypersomnia, hyperphagia and carbohydrate craving (the ATYP scale) before and after treatment. After treatment the patients also self-rated their global improvement on a 10-cm VAS, with anchoring points of 'No improvement' and 'Complete improvement'. VAS ratings were repeated several times, with 1-4 weeks between assessments, in a follow-up period, always referring to improvement in relation to baseline, and accompanied by a statement whether there had been any change since the former VAS rating. Shortly after treatment there was a mean reduction of 59.8% on the MADRS and 57.1% on the ATYP score, and 58.4% improvement as measured by the VAS. VAS rating correlated highly with percentage reduction of MADRS scores (r=0.85) and somewhat less with reduction of ATYP scores (r=0.64). VAS ratings in the follow-up period showed an extremely high test-retest reliability (r=0.96) for two consecutive ratings between which the patient stated that there had been no definite change. The results support the use of VAS ratings for assessment of global improvement after light treatment in patients suffering from W-SAD; use in other kinds of depression and with other types of treatment remains to be explored.