The Can-SAD study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder

Bright Light Therapy for Major Depressive Disorder in Adolescent Outpatients: A Preliminary Study

BACKGROUND

Bright light therapy (BLT) has not been well-studied in adolescents with major depressive disorder, particularly in outpatient settings.

METHODS

We conducted an 8-week clinical trial of BLT in adolescents recruited from a primary care practice with moderate to severe major depression. Acceptability and feasibility were defined by daily use of the light box and integration into daily routines. To assess treatment effects, we utilized the Short Mood and Feelings Questionnaire (SMFQ) and actigraphic sleep variables.

RESULTS

Of the nine enrolled adolescents, the rate of daily use of the light therapy box was 100% at week 2, 78% at week 4 (n = 7), and 67% at weeks 6 and 8 (n = 6). Participants were better able to integrate midday BLT compared to morning BLT into their day-to-day routines. Mean depression scores improved during the 2-week placebo lead-in (dim red light-DRL) and continued to show significant improvement through 6 weeks of BLT. Sleep efficiency increased significantly (p = 0.046), and sleep onset latency showed a trend toward a significant decrease (p = 0.075) in the BLT phase compared to the DRL phase.

CONCLUSION

Bright light treatment that was self-administered at home was feasible, acceptable, and effective for adolescent outpatients with depression. Findings support the development of larger, well-powered, controlled clinical trials of BLT in coordination with primary care.

Circadian preference and mental health outcomes in youth: A systematic review and meta-analysis

Youth is a vulnerable developmental period associated with an increased preference for eveningness and risk for developing psychopathology. Growing evidence suggests a link between eveningness and poorer mental health outcomes, but the findings in the current literature are inconsistent, and a comprehensive synthesis of evidence in this area remains lacking. This meta-analysis aimed to 1) synthesise the existing evidence on the association between circadian preference and mental health outcomes in youths and 2) explore potential sleep-related factors that may moderate the relationship between circadian preference and mental health outcomes. A systematic search of five electronic databases resulted in 81 observational studies included in the review. Eveningness was found to be significantly associated with general mental health (r = 0.20), mood-related disturbances (r = 0.17), and anxiety problems (r = 0.13). The qualitative review also identified that eveningness was associated with greater risks for psychotic symptoms and maladaptive eating behaviours. These findings highlighted the need to consider circadian preference in the clinical management of youth mental health problems. Further research is needed to examine the efficacy of a circadian-focused intervention in the context of youth mental health.

Light Therapy for Adolescent Depression: A Scoping Review

PURPOSE

Depressive disorders in adolescents are a major health concern associated with developmental, social, and educational impairment. Bright Light Therapy (BLT) is a feasible and effective treatment for depressive disorders in adults, but few controlled trials have been conducted with children or adolescents. This scoping review focuses on the current state of knowledge for BLT in the treatment of adolescent depression. We reviewed the literature for novel data and methodologic approaches using BLT and pediatric and young adult populations.

RECENT FINDINGS

BLT is a tolerable treatment with few side effects. However, there is a marked lack of well-powered studies to support BLT as a treatment for depressive disorders in adolescent populations. Given evidence of tolerability and positive treatment effect on depression in the adult literature, research is needed to establish the efficacy, feasibility, and acceptability of BLT in adolescents.

A Nile rat transcriptomic landscape across 22 organs by ultra-deep sequencing and comparative RNA-seq pipeline (CRSP)

RNA sequencing (RNA-seq) has been a widely used high-throughput method to characterize transcriptomic dynamics spatiotemporally. However, RNA-seq data analysis pipelines typically depend on either a sequenced genome and/or corresponding reference transcripts. This limitation is a challenge for species lacking sequenced genomes and corresponding reference transcripts. The Nile rat (Arvicanthis niloticus) has two key features - it is daytime active, and it is prone to diet-induced diabetes, which makes it more similar to humans than regular laboratory rodents. However, at the time of this study, neither a Nile rat genome nor a reference transcript set were available, making it technically challenging to perform large-scale RNA-seq based transcriptomic studies. This genome-independent work progressed concurrently with our generation of a Nile rat genome. A well-annotated genome requires several iterations of manually reviewing curated transcripts and takes years to achieve. Here, we developed a Comparative RNA-Seq Pipeline (CRSP), integrating a comparative species strategy independent of a specific sequenced genome or species-matched reference transcripts. We performed benchmarking to validate that our CRSP tool can accurately quantify gene expression levels. In this study, we generated the first ultra-deep (2.3 billion × 2 paired-end) Nile rat RNA-seq data from 59 biopsy samples representing 22 major organs, providing a unique resource and spatial gene expression reference for Nile rat researchers. Importantly, CRSP is not limited to the Nile rat species and can be applied to any species without prior genomic knowledge. To facilitate a general use of CRSP, we also characterized the number of RNA-seq reads required for accurate estimation via simulation studies. CRSP and documents are available at: https://github.com/pjiang1105/CRSP.

Can Rehabilitative Travel Mobility improve the Quality of Life of Seasonal Affective Disorder Tourists?

Rehabilitation mobility has become a new demand and travel mode for people to pursue active health. A large number of tourists choose to escape the cold in warm places to improve their health every winter. In this study, we collected the health index data of Seasonal Affective Disorder (SAD) tourists from western China before and after their cold escape in Hainan Island in winter, aiming to compare whether rehabilitating cold escape can improve the Quality of Life (QOL) of SAD tourists by hierarchical analysis. Compared with previous studies, this paper has the following contributions: Firstly, the study samples were accurately screened according to the pathogenesis of SAD tourists and the confounding factors were strictly controlled; Secondly, the observational experimental method was used to conduct inter-group and intra-group control studies on 695 samples, and the results were more objective and reliable. Thirdly, the effect of treatment on the quality of life (QOL) of 397 tourists in the rehabilitation mobility group was quantitatively evaluated from three factors including age, gender and sunshine exposure level by multivariate analysis of variance. Research results show that the rehabilitation environment brought by rehabilitation activities can help improve the health status of tourists. Therefore, this paper proposes the concept of “Tourism Therapy” and constructs a theoretical framework. The conclusion of this paper provides a scientific basis and reference for the study of tourism healing as a non-medical alternative therapy.

Vision-Related Quality of Life and Seasonal Affective Disorder in Patients with Glaucoma and Macular Degeneration

Seasonal affective disorder (SAD) is characterized by depressive episodes related to changes in the seasons. Patients with severe vision loss are at an increased risk of SAD. This study seeks to determine the extent to which patients with moderate vision loss report symptoms of SAD. In this cross-sectional, comparative case series, the Seasonal Pattern Assessment Questionnaire (SPAQ) and the National Eye Institute Visual Function Questionnaire (VFQ-39) were used to screen 111 patients with age-related macular degeneration (AMD) and/or primary open-angle glaucoma (POAG). A multiple regression analysis was performed to create a predictive model for SAD based on the Global Seasonality Score (GSS) using the VFQ-39. Subjects who reported symptoms of SAD (GSS > 8) had lower vision-related quality of life (composite score: 57.2 versus 73.2, p < 0.001). Exploratory factor analysis revealed that the items on the VFQ-39 split into two distinct dimensions that together accounted for 63.2% of the total variance in the GSS. One group of questions addressed vision-related problems; the other group comprised questions related to the quality of life. Whereas this model successfully identified patients with vision loss at risk of SAD, a model restricted to the questions available on the shorter, widely used VFQ-25 instrument did not reliably identify patients at risk of SAD.

It's About Time: The Circadian Network as Time-Keeper for Cognitive Functioning, Locomotor Activity and Mental Health

A variety of organisms including mammals have evolved a 24h, self-sustained timekeeping machinery known as the circadian clock (biological clock), which enables to anticipate, respond, and adapt to environmental influences such as the daily light and dark cycles. Proper functioning of the clock plays a pivotal role in the temporal regulation of a wide range of cellular, physiological, and behavioural processes. The disruption of circadian rhythms was found to be associated with the onset and progression of several pathologies including sleep and mental disorders, cancer, and neurodegeneration. Thus, the role of the circadian clock in health and disease, and its clinical applications, have gained increasing attention, but the exact mechanisms underlying temporal regulation require further work and the integration of evidence from different research fields. In this review, we address the current knowledge regarding the functioning of molecular circuits as generators of circadian rhythms and the essential role of circadian synchrony in a healthy organism. In particular, we discuss the role of circadian regulation in the context of behaviour and cognitive functioning, delineating how the loss of this tight interplay is linked to pathological development with a focus on mental disorders and neurodegeneration. We further describe emerging new aspects on the link between the circadian clock and physical exercise-induced cognitive functioning, and its current usage as circadian activator with a positive impact in delaying the progression of certain pathologies including neurodegeneration and brain-related disorders. Finally, we discuss recent epidemiological evidence pointing to an important role of the circadian clock in mental health.

The efficacy of complementary and traditional practice on psychiatric patients with depression symptoms: A meta- analysis study

PURPOSE

This study examined the effect sizes of the complementary and traditional practices on the depressive symptom levels in psychiatric patients DESIGN AND METHODS: The "Health Evidence™ Quality Assessment Tool" and "Comprehensive Meta-Analysis 3" program was used.

FINDINGS

A total of 81 studies with 5934 patients were included. The effect size of the complementary and traditional methods applied to psychiatric patient on depressive symptoms was calculated as d = 0.718 (p = 0.000). According to Cohen, studies have moderate effect size.

PRACTICE IMPLICATIONS

Complementary and traditional practices were found to be significant and effective on depressive symptoms in psychiatric patients.

Validity and Usage of the Seasonal Pattern Assessment Questionnaire (SPAQ) in a French Population of Patients with Depression, Bipolar Disorders and Controls

The Seasonal Pattern Assessment Questionnaire (SPAQ), by Rosenthal et al. (1984), is by far the most used questionnaire to evaluate seasonal effects on mood and behavior. It includes a general seasonality score (GSS), composed of 6 items, from which cutoffs have been established to screen for seasonal affective disorder (SAD). However, it has never been validated in French and associations with circadian rhythm and symptoms of depression and bipolarity remain unclear. In this study, including 165 subjects (95 controls and 70 patients with depression or bipolar disorder), we confirmed the validity of the French version of the SPAQ, with a two-factor structure (a psychological factor: energy, mood, social activity and sleep length; and a food factor: weight and appetite) and a good fit was observed by all indicators. Mood and social activity dimensions were significantly affected by seasons in the depressed/bipolar group and a stronger global seasonality score (GSS) was associated with more severe phenotypes of depression and mania. Subjects meeting SAD and subsyndromal-SAD criteria also showed a delayed circadian rhythm compared to controls. Simple tools, such as the SPAQ, can aid the identification of significant seasonal changes and have direct implications on therapeutics including the use of bright light therapy in order to enhance personalized treatments, but also to prevent adverse seasonal effects.

Second-generation antidepressants for treatment of seasonal affective disorder

BACKGROUND

Seasonal affective disorder (SAD) is a seasonal pattern of recurrent depressive episodes that is often treated with second-generation antidepressants (SGAs), light therapy, or psychotherapy.

OBJECTIVES

To assess the efficacy and safety of second-generation antidepressants (SGAs) for the treatment of seasonal affective disorder (SAD) in adults in comparison with placebo, light therapy, other SGAs, or psychotherapy.

SEARCH METHODS

This is an update of an earlier review first published in 2011. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 1) in the Cochrane Library (all years), Ovid MEDLINE, Embase, and PsycINFO (2011 to January 2020), together with the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) (all available years), for reports of randomised controlled trials (RCTs). We hand searched the reference lists of all included studies and other systematic reviews. We searched ClinicalTrials.gov for unpublished/ongoing trials. We ran a separate update search for reports of adverse events in the Ovid databases.  SELECTION CRITERIA: For efficacy we included RCTs of SGAs compared with other SGAs, placebo, light therapy, or psychotherapy in adult participants with SAD. For adverse events we also included non-randomised studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and full-text publications against the inclusion criteria. Data extraction and 'Risk of bias' assessment were conducted individually. We pooled data for meta-analysis where the participant groups were similar, and the studies assessed the same treatments with the same comparator and had similar definitions of outcome measures over a similar duration of treatment.

MAIN RESULTS

In this update we identified no new RCT on the effectiveness of SGAs in SAD patients. We included 2 additional single-arm observational studies that reported on adverse events of SGAs.  For efficacy we included three RCTs of between five and eight weeks' duration with a total of 204 participants. For adverse events we included two RCTs and five observational (non-randomised) studies of five to eight weeks' duration with a total of 249 participants. All participants met the DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria for SAD. The average age ranged from 34 to 42 years, and the majority of participants were female (66% to 100%). Results from one trial with 68 participants showed that fluoxetine (20/36) was numerically superior to placebo (11/32) in achieving clinical response; however, the confidence interval (CI) included both a potential benefit as well as no benefit of fluoxetine (risk ratio (RR) 1.62, 95% CI 0.92 to 2.83, very low-certainty evidence). The number of adverse events was similar in both groups (very low-certainty evidence). Two trials involving a total of 136 participants compared fluoxetine versus light therapy. Meta-analysis showed fluoxetine and light therapy to be approximately equal in treating seasonal depression: RR of response 0.98 (95% CI 0.77 to 1.24, low-certainty evidence), RR of remission 0.81 (95% CI 0.39 to 1.71, very low-certainty evidence). The number of adverse events was similar in both groups (low-certainty evidence). We did not identify any eligible study comparing SGA with another SGA or with psychotherapy. Two RCTs and five non-randomised studies reported adverse event data on a total of 249 participants who received bupropion, fluoxetine, escitalopram, duloxetine, nefazodone, reboxetine, light therapy, or placebo. We were only able to obtain crude rates of adverse events, therefore caution is advised regarding interpretation of this information. Between 0% and 100% of participants who received an SGA suffered an adverse event, and between 0% and 25% of participants withdrew from the study due to adverse events.

AUTHORS' CONCLUSIONS

Evidence for the effectiveness of SGAs is limited to one small trial of fluoxetine compared with placebo showing a non-significant effect in favour of fluoxetine, and two small trials comparing fluoxetine against light therapy suggesting equivalence between the two interventions. The lack of available evidence precluded us from drawing any overall conclusions on the use of SGAs for SAD. Further, larger RCTs are required to expand and strengthen the evidence base on this topic, and should also include comparisons with psychotherapy and other SGAs. Data on adverse events were sparse, and a comparative analysis was not possible. The data we obtained on adverse events is therefore not robust, and our confidence in the data is limited. Overall, up to 25% of participants treated with SGAs for SAD withdrew from the study early due to adverse events.

"Shedding Light on Light": A Review on the Effects on Mental Health of Exposure to Optical Radiation

In relation to human health and functioning, light, or more specifically optical radiation, plays many roles, beyond allowing vision. These may be summarized as: regulation of circadian rhythms; consequences of direct exposure to the skin; and more indirect effects on well-being and functioning, also related to lifestyle and contact with natural and urban environments. Impact on mental health is relevant for any of these specifications and supports a clinical use of this knowledge for the treatment of psychiatric conditions, such as depression or anxiety, somatic symptom disorder, and others, with reference to light therapy in particular. The scope of this narrative review is to provide a summary of recent findings and evidence on the regulating functions of light on human beings’ biology, with a specific focus on mental health, its prevention and care.

The darkness and the light: diurnal rodent models for seasonal affective disorder

The development of animal models is a critical step for exploring the underlying pathophysiological mechanisms of major affective disorders and for evaluating potential therapeutic approaches. Although most neuropsychiatric research is performed on nocturnal rodents, differences in how diurnal and nocturnal animals respond to changing photoperiods, combined with a possible link between circadian rhythm disruption and affective disorders, has led to a call for the development of diurnal animal models. The need for diurnal models is most clear for seasonal affective disorder (SAD), a widespread recurrent depressive disorder that is linked to exposure to short photoperiods. Here, we briefly review what is known regarding the etiology of SAD and then examine progress in developing appropriate diurnal rodent models. Although circadian disruption is often invoked as a key contributor to SAD, a mechanistic understanding of how misalignment between endogenous circadian physiology and daily environmental rhythms affects mood is lacking. Diurnal rodents show promise as models of SAD, as changes in affective-like behaviors are induced in response to short photoperiods or dim-light conditions, and symptoms can be ameliorated by brief exposure to intervals of bright light coincident with activity onset. One exciting avenue of research involves the orexinergic system, which regulates functions that are disturbed in SAD, including sleep cycles, the reward system, feeding behavior, monoaminergic neurotransmission and hippocampal neurogenesis. However, although diurnal models make intuitive sense for the study of SAD and are more likely to mimic circadian disruption, their utility is currently hampered by a lack of genomic resources needed for the molecular interrogation of potential mechanisms.

Light therapy for mood disorders

In this chapter, light therapy for mood disorders is discussed, including mood disorders during and after pregnancy. In the introduction, we discuss the symptomatology, etiology, and treatment of a specific type of mood disorder, seasonal affective disorder, since it kick-started the first clinical trials with light therapy. Second, we elaborate on the pathophysiology of mood disorders, in particular in the peripartum period. Next, we present an overview of the proposed working mechanisms of light therapy, followed by a discussion of the clinical trials that have followed after the initial research in seasonal affective disorder. Finally, we also focus on the limitations of these trials, such as considerable heterogeneity among studies and many methodological shortcomings. This is complemented by a number of suggestions for future research. Further studies are needed, which stems from the fact that the results have not always been consistent. Despite this, light therapy may be a promising treatment option for various types of mood disorders, since it shows a significant reduction in symptoms in many patients with few adverse effects.

The therapeutic effects and safety of bright light therapy combined with escitalopram oxalate on insomnia in patients with poststroke depression

INTRODUCTION

Bright light therapy (BLT) is known to treat depression and sleep disorders in clinical practice, but its efficacy on poststroke depression (PSD) has not been studied.

OBJECTIVE

To investigate the therapeutic effects and safety of BLT combined with escitalopram oxalate (ESC) on insomnia in patients with PSD.

METHODS

Ischemic stroke patients with depressive symptoms and a score of ≥8 on the Hamilton Depression Scale (HAMD-17) while meeting DSM-IV criteria were diagnosed as having PSD. A total of 112 PSD patients with symptoms of insomnia were randomly assigned to polytherapy (BLT plus ESC) and monotherapy (ESC only) groups. Each regimen continued for 6 weeks. The primary outcomes were a change in scores on the Pittsburgh Sleep Quality Index (PSQI) and a remission rate (PSQI ≤7 at the endpoint). The secondary outcomes included changes in the HAMD-17 and Barthel Index (BI) scores. Adverse effects were assessed by the Adverse Events Scale.

RESULTS

The endpoint assessment included 106 patients (monotherapy, 54; polytherapy, 52). The mean changes in the PSQI scores for the monotherapy and polytherapy groups were 4.85 (1.47) and 5.87 (1.72) (P = 0.001), respectively. Compared to monotherapy, polytherapy improved PSQI remission rate (71.4% vs 50.0%; χ2 = 5.390; P = 0.020), and HAMD-17 score (6.70 [2.12] vs 4.75 [1.98]; P < 0.001). Both treatments improved BI score, with no statistical difference, and were well tolerated, with few significant differences in treatment-associated adverse events.

CONCLUSION

BLT combined with ESC is effective and well tolerated for the treatment of PSD-associated insomnia.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Rhythms, Reward, and Blues: Consequences of Circadian Photoperiod on Affective and Reward Circuit Function

Circadian disruptions, along with altered affective and reward states, are commonly associated with psychiatric disorders. In addition to genetics, the enduring influence of environmental factors in programming neural networks is of increased interest in assessing the underpinnings of mental health. The duration of daylight or photoperiod is known to impact both the serotonin and dopamine systems, which are implicated in mood and reward-based disorders. This review first examines the effects of circadian disruption and photoperiod in the serotonin system in both human and preclinical studies. We next highlight how brain regions crucial for the serotoninergic system (i.e., dorsal raphe nucleus; DRN), and dopaminergic (i.e., nucleus accumbens; NAc and ventral tegmental area; VTA) system are intertwined in overlapping circuitry, and play influential roles in the pathology of mood and reward-based disorders. We then focus on human and animal studies that demonstrate the impact of circadian factors on the dopaminergic system. Lastly, we discuss how environmental factors such as circadian photoperiod can impact the neural circuits that are responsible for regulating affective and reward states, offering novel insights into the biological mechanisms underlying the pathophysiology, systems, and therapeutic treatments necessary for mood and reward-based disorders.

Bioethical Issues in Antarctica

This paper describes the Antarctic environment, the mission and work setting at the U.S. research stations, the general population and living conditions, and the healthcare situation. It also dispels some common misconceptions that persist about this environment and about the scope and quality of medicine practiced there. The paper then describes specific ethical issues that arise in this environment, incorporating examples drawn from both the author's experiences and those of his colleagues. The ethics of providing healthcare in resource-poor environments implies two related questions. The first is: What can we do with the available resources? This suggests that clinicians must not only know how to use all available equipment and supplies in the standard manner, but also that they must be willing and able to go beyond standard procedures and improvise, when necessary. The second question is: Of all the things we can do, which ones should we do? This paper addresses both questions in relation to Antarctic medical care. It describes the wide range of activities required of healthcare providers and some specific ethical issues that arise. Finally, it suggests some remedies to ameliorate some of those issues.

Detecting Critical Decision Points during Cognitive-Behavioral Therapy and Light Therapy for Winter Depression Nonremission and Recurrence

Using data from a clinical trial comparing cognitive-behavioral therapy (CBT-SAD) and light therapy (LT) for winter seasonal affective disorder (SAD; N = 177), we explored critical decision points, or treatment weeks, that predict likelihood of nonremission at post-treatment and depression recurrence following treatment. In receiver operator characteristic (ROC) curve analyses, we used weekly Structured Clinical Interview for the Hamilton Rating Scale for Depression-SAD Version (SIGH-SAD) scores during treatment to predict nonremission at post-treatment (Week 6) and recurrence one winter later (Winter 1), two winters later (Winter 2), and any recurrence. Although several C-statistics of ≥ .70 were found, only Week 4 SIGH-SAD scores in CBT-SAD for nonremission had enough predictive ability to inform clinical decision-making (C-statistic = .80; sensitivity = .91; specificity = .68). Week 4 of CBT-SAD may be a critical time point to identify likely nonremitters who need tailoring of intervention, based on SIGH-SAD cutpoint score ≥ 13. This study illustrates how clinical trial data can inform detecting optimal decision points in treatment for identifying patients unlikely to remit, a critical first step to developing adaptive treatment strategies using decision rules to operationalize when and for whom treatment should change to maximize clinical benefit.

A within-subject comparison of different relaxation therapies in eliciting physiological and psychological changes in young women

Background

Stress reactivity can be different in women compared to men, which might consequently influence disease risk.Stress in women may also generate adverse physiological effects on their offspring during pregnancy or lactation. The objective of this study was to compare the effects of different relaxation interventions on physiological outcomes and perceived relaxation in healthy young women, to assist in identifying the most appropriate intervention(s) for use in a subsequent trial for mothers who deliver prematurely.

Methods

A within-subject study was conducted in 17 women of reproductive age comparing five different relaxation interventions (guided-imagery meditation audio (GIM), music listening (ML), relaxation lighting (RL), GIM+RL, ML+RL), with control (silence/sitting), assigned in random order over a 3–6 week period. Subjective feelings of relaxation (10-point scale), heart rate (HR), systolic and diastolic blood pressure (SBP, DBP), and fingertip temperature (FT) were measured before and after each technique

Results

All interventions significantly increased perceived relaxation and FT, while music also significantly reduced SBP (p < 0.05). Compared to control, HR significantly decreased following GIM (mean difference = 3.2 bpm, p < 0.05), and FT increased (mean difference = 2.2 °C, p < 0.05) and SBP decreased (mean difference = 3.3 mmHg, p < 0.01) following ML. GIM + RL followed by GIM were the most preferred interventions.

Conclusions

Based on preference, simplicity, and the physiological and psychological effects, GIM and ML were identified as the most effective tools for reducing stress and improving relaxation. These techniques warrant further research in larger samples and other populations.

Cognitive Vulnerabilities as Prognostic Predictors of Acute and Follow-up Outcomes in Seasonal Affective Disorder Treatment with Light Therapy or Cognitive-Behavioral Therapy

BACKGROUND

First-line treatments for winter seasonal affective disorder include light therapy and cognitive-behavioral therapy; however, it is unclear whether particular patient profiles respond differentially to each treatment type. This study examined baseline patient cognitive and chronobiological vulnerabilities as prognostic and prescriptive predictors of acute and follow-up treatment outcomes.

METHODS

177 adults with seasonal affective disorder were randomized to 6-weeks of either light therapy or cognitive-behavioral therapy. Participants completed baseline measures of cognitive vulnerabilities (Dysfunctional Attitudes Scale; Ruminative Response Scale; Seasonal Belief Questionnaire) and chronobiological vulnerability (Morningness-Eveningness Questionnaire). Depression was assessed at pre- and post-treatment and at follow-ups one and two winters later.

RESULTS

Pre-treatment depression severity correlated significantly with each cognitive vulnerability measure, and significantly predicted future depression. After controlling for pre-treatment depression, higher scores on the Morningness-Eveningness Questionnaire were prognostic of lower depression at treatment endpoint, but no cognitive vulnerability emerged as a prognostic or prescriptive predictor of outcome.

CONCLUSIONS

Greater morningness was associated with less severe post-treatment depression in both cognitive-behavior therapy and light therapy. No cognitive vulnerability emerged as a prognostic or prescriptive predictor, perhaps because they correlated with pre-treatment depression severity, a robust predictor of outcome. Future research should test alternative cognitive constructs.

New insights on the role of the retina in diagnostic and therapeutic strategies in major depressive disorder

Major depressive disorder (MDD) affects people worldwide. MDD treatments include antidepressants, which involve a delayed onset of action, long-term treatment, side effects and, frequently, only partial efficacy. The lack of access to the living brain, and the complex and still poorly elucidated pathophysiology of MDD, hinders treatment development. There is not only a need for new treatment strategies, but also for new approaches to investigating the pathophysiology of MDD. Light therapy is a well-established treatment acting through the retina. Since the retina is part of the central nervous system, it has been suggested as a useful area for investigating mental illness. In this article, we will first set out the evidence that MDD affects the retina's structure and function. We will then review studies evaluating the efficacy of light therapy in unipolar non-seasonal MDD. Finally, we discuss the disruption of melatoninergic pathways in MDD, its assessment through the retina and the treatment of this disruption with light therapy.

An examination of the relationship between sunlight exposure and hot flush in working women

We examined whether sunlight affects hot flushes in working menopausal women and explored effect modification by shift work and season. In this prospective cohort study, daily hot flush score (outcome) was measured by the 7-day North Central Cancer Treatment Group Daily Vasomotor Symptoms Diary. Daily duration of sunlight (≥2000 lux) was recorded by the HOBO MX2202 pendant. Both variables were measured in two 7-day data collection phases. T0 data were collected during the Australian Summer (December 2017, January and February 2018); and T1 data were collected in the Australian winter (June, July and August 2018). Linear mixed effects model was used. Shift work and season were both confounders and effect modifiers. To detect a median effect size of R² = 0.2, 34 women were required to achieve an effective sample size of 41. A total of 49 menopausal women were recruited, 11 shift and 38 day workers. Some 13 women had various missing observations. For shift workers, an hour increase in sunlight exposure was associated with a 1.4-point reduction in hot flush score (p = .016). This relationship was not significant for day workers (p = .185). The finding of this study suggests increased sunlight exposure might improve hot flushes in menopausal shift workers who are moderately bothered by hot flushes, but probably not in day workers. The possible role of shift-work associated circadian disruption on estrogen level in regard to elevated intensity and frequency of hot flush in menopausal women is discussed.

Seasonal affective disorder and seasonal changes in weight and sleep duration are inversely associated with plasma adiponectin levels

Overlapping pathways between mood and metabolic regulation have increasingly been reported. Although impaired regulation of adiponectin, a major metabolism-regulating hormone, has been implicated in major depressive disorder, its role in seasonal changes in mood and seasonal affective disorder-winter type (SAD), a disorder characterized by onset of mood impairment and metabolic dysregulation (e.g., carbohydrate craving and weight gain) in fall/winter and spontaneous alleviation in spring/summer, has not been previously studied. We studied a convenience sample of 636 Old Order Amish (mean (± SD), 53.6 (±14.8) years; 50.1% males), a population with self-imposed restriction on network electric light at home, and low prevalence of total SAD (t-SAD = syndromal + subsyndromal). We calculated the global seasonality score (GSS), estimated SAD and subsyndromal-SAD after obtaining Seasonal Pattern Assessment Questionnaires (SPAQs), and measured overnight fasting plasma adiponectin levels. We then tested associations between plasma adiponectin levels and GSS, t-SAD, winter-summer difference in self-reported sleep duration, and self-reported seasonal weight change, by using analysis of co-variance (ANCOVA) and linear regression analysis after adjusting for age, gender, and BMI. Participants with t-SAD (N = 14; 2.2%) had significantly lower plasma adiponectin levels (mean ± SEM, 8.76 ± 1.56 μg/mL) than those without t-SAD (mean ± SEM, 11.93 ± 0.22 μg/mL) (p = 0.035). In addition, there was significant negative association between adiponectin levels and winter-summer difference in self-reported sleep duration (p = 0.025) and between adiponectin levels and self-reported seasonal change in weight (p = 0.006). There was no significant association between GSS and adiponectin levels (p = 0.88). To our knowledge, this is the first study testing the association of SAD with adiponectin levels. Replication and extension of our findings longitudinally and, then, interventionally, may implicate low adiponectin as a novel target for therapeutic intervention in SAD.

The chronotherapeutic treatment of bipolar disorders: A systematic review and practice recommendations from the ISBD task force on chronotherapy and chronobiology

AIMS

To systematically review the literature on the efficacy and tolerability of the major chronotherapeutic treatments of bipolar disorders (BD)-bright light therapy (LT), dark therapy (DT), treatments utilizing sleep deprivation (SD), melatonergic agonists (MA), interpersonal social rhythm therapy (IPSRT), and cognitive behavioral therapy adapted for BD (CBTI-BP)-and propose treatment recommendations based on a synthesis of the evidence.

METHODS

PRISMA-based systematic review of the literature.

RESULTS

The acute antidepressant (AD) efficacy of LT was supported by several open-label studies, three randomized controlled trials (RCTs), and one pseudorandomized controlled trial. SD showed rapid, acute AD response rates of 43.9%, 59.3%, and 59.4% in eight case series, 11 uncontrolled, studies, and one RCT, respectively. Adjunctive DT obtained significant, rapid anti-manic results in one RCT and one controlled study. The seven studies on MA yielded very limited data on acute antidepressant activity, conflicting evidence of both antimanic and maintenance efficacy, and support from two case series of improved sleep in both acute and euthymic states. IPSRT monotherapy for bipolar II depression had acute response rates of 41%, 67%, and 67.4% in two open studies and one RCT, respectively; as adjunctive therapy for bipolar depression in one RCT, and efficacy in reducing relapse in two RCTs. Among euthymic BD subjects with insomnia, a single RCT found CBTI-BP effective in delaying manic relapse and improving sleep. Chronotherapies were generally safe and well-tolerated.

CONCLUSIONS

The outcome literature on the adjunctive use of chronotherapeutic treatments for BP is variable, with evidence bases that differ in size, study quality, level of evidence, and non-standardized treatment protocols. Evidence-informed practice recommendations are offered.

Direct sunlight exposure reduces hair cortisol levels in rhesus monkeys (Macaca mulatta)

Major depressive disorder (MDD), commonly known as depression, is a mental disease characterized by a core symptom of low mood. It lasts at least two weeks (Badamasi et al., 2019; Wang et al., 2019) and is frequently accompanied by low self-esteem, loss of interest in routinely enjoyable activities, low energy, and unexplained pain (Huey et al., 2018; Park et al., 2012; Post & Warden, 2018; Rice et al., 2019; Xiao et al., 2018). Approximately 2%-8% of adults with MDD commit suicide (Richards & O'Hara, 2014; Strakowski & Nelson, 2015), and around half of suicidal individuals suffer depression or other mood disorders (Bachmann, 2018).

Photoperiod-induced neurotransmitter plasticity declines with aging: An epigenetic regulation?

Neuroplasticity has classically been understood to arise through changes in synaptic strength or synaptic connectivity. A newly discovered form of neuroplasticity, neurotransmitter switching, involves changes in neurotransmitter identity. Chronic exposure to different photoperiods alters the number of dopamine (tyrosine hydroxylase, TH+) and somatostatin (SST+) neurons in the paraventricular nucleus (PaVN) of the hypothalamus of adult rats and results in discrete behavioral changes. Here, we investigate whether photoperiod-induced neurotransmitter switching persists during aging and whether epigenetic mechanisms of histone acetylation and DNA methylation may contribute to this neurotransmitter plasticity. We show that this plasticity in rats is robust at 1 and at 3 months but reduced in TH+ neurons at 12 months and completely abolished in both TH+ and SST+ neurons by 18 months. De novo expression of DNMT3a catalyzing DNA methylation and anti-AcetylH3 assessing histone 3 acetylation were observed following short-day photoperiod exposure in both TH+ and SST+ neurons at 1 and 3 months while an overall increase in DNMT3a in SST+ neurons paralleled neuroplasticity reduction at 12 and 18 months. Histone acetylation increased in TH+ neurons and decreased in SST+ neurons following short-day exposure at 3 months while the total number of anti-AcetylH3+ PaVN neurons remained constant. Reciprocal histone acetylation in TH+ and SST+ neurons indicates the importance of studying epigenetic regulation at the circuit level for identified cell phenotypes. The findings may be useful for developing approaches for noninvasive treatment of disorders characterized by neurotransmitter dysfunction.

Melatonin and agomelatine for preventing seasonal affective disorder

BACKGROUND

Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly starts in autumn or winter and remits in spring. The prevalence of SAD depends on latitude and ranges from 1.5% to 9%. The predictable seasonal aspect of SAD provides a promising opportunity for prevention in people who have a history of SAD. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on agomelatine and melatonin as preventive interventions.

OBJECTIVES

To assess the efficacy and safety of agomelatine and melatonin (in comparison with each other, placebo, second-generation antidepressants, light therapy, psychological therapy or lifestyle interventions) in preventing SAD and improving person-centred outcomes among adults with a history of SAD.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library, the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles.

SELECTION CRITERIA

To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter-type SAD who were free of symptoms at the beginning of the study. For adverse events, we intended also to include non-randomised studies. We planned to include studies that compared agomelatine versus melatonin, or agomelatine or melatonin versus placebo, any second-generation antidepressant, light therapy, psychological therapies or lifestyle changes. We also intended to compare melatonin or agomelatine in combination with any of the comparator interventions mentioned above versus the same comparator intervention as monotherapy.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full-text publications, abstracted data and assessed risk of bias of included studies independently. We intended to pool data in a meta-analysis using a random-effects model, but included only one study.

MAIN RESULTS

We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 full-text papers for inclusion in the review. Only one study, providing data of 225 participants, met our eligibility criteria and compared agomelatine (25 mg/day) with placebo. We rated it as having high risk of attrition bias because nearly half of the participants left the study before completion. We rated the certainty of the evidence as very low for all outcomes, because of high risk of bias, indirectness, and imprecision.The main analysis based on data of 199 participants rendered an indeterminate result with wide confidence intervals (CIs) that may encompass both a relevant reduction as well as a relevant increase of SAD incidence by agomelatine (risk ratio (RR) 0.83, 95% CI 0.51 to 1.34; 199 participants; very low-certainty evidence). Also the severity of SAD may be similar in both groups at the end of the study with a mean SIGH-SAD (Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders) score of 8.3 (standard deviation (SD) 9.4) in the agomelatine group and 10.1 (SD 10.6) in the placebo group (mean difference (MD) -1.80, 95% CI -4.58 to 0.98; 199 participants; very low-certainty evidence). The incidence of adverse events and serious adverse events may be similar in both groups. In the agomelatine group, 64 out of 112 participants experienced at least one adverse event, while 61 out of 113 did in the placebo group (RR 1.06, 95% CI 0.84 to 1.34; 225 participants; very low-certainty evidence). Three out of 112 patients experienced serious adverse events in the agomelatine group, compared to 4 out of 113 in the placebo group (RR 0.76, 95% CI 0.17 to 3.30; 225 participants; very low-certainty evidence).No data on quality of life or interpersonal functioning were reported. We did not identify any studies on melatonin.

AUTHORS' CONCLUSIONS

Given the uncertain evidence on agomelatine and the absence of studies on melatonin, no conclusion about efficacy and safety of agomelatine and melatonin for prevention of SAD can currently be drawn. The decision for or against initiating preventive treatment of SAD and the treatment selected should consider patient preferences and reflect on the evidence base of all available treatment options.

Psychological therapies for preventing seasonal affective disorder

BACKGROUND

Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly occurs during autumn or winter and remits in spring. The prevalence of SAD ranges from 1.5% to 9%, depending on latitude. The predictable seasonal aspect of SAD provides a promising opportunity for prevention. This is one of four reviews on the efficacy and safety of interventions to prevent SAD; we focus on psychological therapies as preventive interventions.

OBJECTIVES

To assess the efficacy and safety of psychological therapies (in comparison with no treatment, other types of psychological therapy, second-generation antidepressants, light therapy, melatonin or agomelatine or lifestyle interventions) in preventing SAD and improving person-centred outcomes among adults with a history of SAD.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library, the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles.

SELECTION CRITERIA

To examine efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter-type SAD who were free of symptoms at the beginning of the study. To examine adverse events, we intended to include non-randomised studies. We planned to include studies that compared psychological therapy versus no treatment, or any other type of psychological therapy, light therapy, second-generation antidepressants, melatonin, agomelatine or lifestyle changes. We also planned to compare psychological therapy in combination with any of the comparator interventions listed above versus no treatment or the same comparator intervention as monotherapy.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full-text publications against the inclusion criteria, independently extracted data, assessed risk of bias, and graded the certainty of evidence.

MAIN RESULTS

We identified 3745 citations through electronic searches and reviews of reference lists after deduplication of search results. We excluded 3619 records during title and abstract review and assessed 126 articles at full-text review for eligibility. We included one controlled study enrolling 46 participants. We rated this RCT at high risk for performance and detection bias due to a lack of blinding.The included RCT compared preventive use of mindfulness-based cognitive therapy (MBCT) with treatment as usual (TAU) in participants with a history of SAD. MBCT was administered in spring in eight weekly individual 45- to 60-minute sessions. In the TAU group participants did not receive any preventive treatment but were invited to start light therapy as first depressive symptoms occurred. Both groups were assessed weekly for occurrence of a new depressive episode measured with the Inventory of Depressive Syptomatology-Self-Report (IDS-SR, range 0-90) from September 2011 to mid-April 2012. The incidence of a new depressive episode in the upcoming winter was similar in both groups. In the MBCT group 65% of 23 participants developed depression (IDS-SR ≥ 20), compared to 74% of 23 people in the TAU group (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.60 to 1.30; 46 participants; very low quality-evidence).For participants with depressive episodes, severity of depression was comparable between groups. Participants in the MBCT group had a mean score of 26.5 (SD 7.0) on the IDS-SR, and TAU participants a mean score of 25.3 (SD 6.3) (mean difference (MD) 1.20, 95% CI -3.44 to 5.84; 32 participants; very low quality-evidence).The overall discontinuation rate was similar too, with 17% discontinuing in the MBCT group and 13% in the TAU group (RR 1.33, 95% CI 0.34 to 5.30; 46 participants; very low quality-evidence).Reasons for downgrading the quality of evidence included high risk of bias of the included study and imprecision.Investigators provided no information on adverse events. We could not find any studies that compared psychological therapy with other interventions of interest such as second-generation antidepressants, light therapy, melatonin or agomelatine.

AUTHORS' CONCLUSIONS

The evidence on psychological therapies to prevent the onset of a new depressive episode in people with a history of SAD is inconclusive. We identified only one study including 46 participants focusing on one type of psychological therapy. Methodological limitations and the small sample size preclude us from drawing a conclusion on benefits and harms of MBCT as a preventive intervention for SAD. Given that there is no comparative evidence for psychological therapy versus other preventive options, the decision for or against initiating preventive treatment of SAD and the treatment selected should be strongly based on patient preferences and other preventive interventions that are supported by evidence.

Use of "Lights" for Bipolar Depression

PURPOSE

In this review, we will review the background and diagnosis of bipolar disorder (BD); describe the efficacy data and potential circadian and neural mechanisms underlying the effects of bright light for bipolar depression; and discuss the implementation of light therapy in clinical practice.

RECENT FINDINGS

To date, morning bright light is the most widely tested form of light therapy for all mood disorders. Clinical trial reports suggest that midday or morning bright light treatment and novel chronotherapeutic interventions are effective for bipolar depression. Mechanisms of response may relate to effects on the circadian system and other changes in neural functioning. Using bright light to manage depressive symptoms in BD is reasonable but also requires concurrent antimanic treatment and careful clinical monitoring for response, safety, and mood polarity switch.

Light as a modulator of emotion and cognition: Lessons learned from studying a diurnal rodent

Light profoundly affects the behavior and physiology of almost all animals, including humans. One such effect in humans is that the level of illumination during the day positively contributes to affective well-being and cognitive function. However, the neural mechanisms underlying the effects of daytime light intensity on affect and cognition are poorly understood. One barrier for progress in this area is that almost all laboratory animal models studied are nocturnal. There are substantial differences in how light affects nocturnal and diurnal species, e.g., light induces sleep in nocturnal mammals but wakefulness in diurnal ones, like humans. Therefore, the mechanisms through which light modulates affect and cognition must differ between the chronotypes. To further understand the neural pathways mediating how ambient light modulates affect and cognition, our recent work has developed a diurnal rodent model, the Nile grass rat (Arvicanthis niloticus), in which daytime light intensity is chronically manipulated in grass rats housed under the same 12:12 hour light/dark cycle. This simulates lighting conditions during summer-like bright sunny days vs. winter-like dim cloudy days. Our work has revealed that chronic dim daylight intensity results in higher depression- and anxiety-like behaviors, as well as impaired spatial learning and memory. Furthermore, we have found that hypothalamic orexin is a mediator of these effects. A better understanding of how changes in daytime light intensity impinge upon the neural substrates involved in affect and cognition will lead to novel preventive and therapeutic strategies for seasonal affective disorder, as well as for non-seasonal emotional or cognitive impairments associated with light deficiency.

Light therapy for preventing seasonal affective disorder

BACKGROUND

Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly occurs during autumn or winter and remits in spring. The prevalence of SAD ranges from 1.5% to 9%, depending on latitude. The predictable seasonal aspect of SAD provides a promising opportunity for prevention. This review - one of four reviews on efficacy and safety of interventions to prevent SAD - focuses on light therapy as a preventive intervention. Light therapy is a non-pharmacological treatment that exposes people to artificial light. Mode of delivery and form of light vary.

OBJECTIVES

To assess the efficacy and safety of light therapy (in comparison with no treatment, other types of light therapy, second-generation antidepressants, melatonin, agomelatine, psychological therapies, lifestyle interventions and negative ion generators) in preventing SAD and improving patient-centred outcomes among adults with a history of SAD.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library, the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles.

SELECTION CRITERIA

For efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter-type SAD who were free of symptoms at the beginning of the study. For adverse events, we also intended to include non-randomised studies. We intended to include studies that compared any type of light therapy (e.g. bright white light, administered by visors or light boxes, infrared light, dawn stimulation) versus no treatment/placebo, second-generation antidepressants, psychological therapies, melatonin, agomelatine, lifestyle changes, negative ion generators or another of the aforementioned light therapies. We also planned to include studies that looked at light therapy in combination with any comparator intervention.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full-text publications, independently abstracted data and assessed risk of bias of included studies.

MAIN RESULTS

We identified 3745 citations after de-duplication of search results. We excluded 3619 records during title and abstract review. We assessed 126 full-text papers for inclusion in the review, but only one study providing data from 46 people met our eligibility criteria. The included RCT had methodological limitations. We rated it as having high risk of performance and detection bias because of lack of blinding, and as having high risk of attrition bias because study authors did not report reasons for dropouts and did not integrate data from dropouts into the analysis.The included RCT compared preventive use of bright white light (2500 lux via visors), infrared light (0.18 lux via visors) and no light treatment. Overall, white light and infrared light therapy reduced the incidence of SAD numerically compared with no light therapy. In all, 43% (6/14) of participants in the bright light group developed SAD, as well as 33% (5/15) in the infrared light group and 67% (6/9) in the non-treatment group. Bright light therapy reduced the risk of SAD incidence by 36%; however, the 95% confidence interval (CI) was very broad and included both possible effect sizes in favour of bright light therapy and those in favour of no light therapy (risk ratio (RR) 0.64, 95% CI 0.30 to 1.38; 23 participants, very low-quality evidence). Infrared light reduced the risk of SAD by 50% compared with no light therapy, but the CI was also too broad to allow precise estimations of effect size (RR 0.50, 95% CI 0.21 to 1.17; 24 participants, very low-quality evidence). Comparison of both forms of preventive light therapy versus each other yielded similar rates of incidence of depressive episodes in both groups (RR 1.29, 95% CI 0.50 to 3.28; 29 participants, very low-quality evidence). Reasons for downgrading evidence quality included high risk of bias of the included study, imprecision and other limitations, such as self-rating of outcomes, lack of checking of compliance throughout the study duration and insufficient reporting of participant characteristics.Investigators provided no information on adverse events. We could find no studies that compared light therapy versus other interventions of interest such as second-generation antidepressants, psychological therapies, melatonin or agomelatine.

AUTHORS' CONCLUSIONS

Evidence on light therapy as preventive treatment for people with a history of SAD is limited. Methodological limitations and the small sample size of the only available study have precluded review author conclusions on effects of light therapy for SAD. Given that comparative evidence for light therapy versus other preventive options is limited, the decision for or against initiating preventive treatment of SAD and the treatment selected should be strongly based on patient preferences.

Second-generation antidepressants for preventing seasonal affective disorder in adults

BACKGROUND

Seasonal affective disorder (SAD) is a seasonal pattern of recurrent major depressive episodes that most commonly occurs during autumn or winter and remits in spring. The prevalence of SAD ranges from 1.5% to 9%, depending on latitude. The predictable seasonal aspect of SAD provides a promising opportunity for prevention. This review - one of four reviews on efficacy and safety of interventions to prevent SAD - focuses on second-generation antidepressants (SGAs).

OBJECTIVES

To assess the efficacy and safety of SGAs (in comparison with other SGAs, placebo, light therapy, melatonin or agomelatine, psychological therapies or lifestyle interventions) in preventing SAD and improving patient-centred outcomes among adults with a history of SAD.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 19 June 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 11 August 2015). Furthermore, we searched the Cumulative Index to Nursing and Allied Health Literature, Web of Science, the Cochrane Library, the Allied and Complementary Medicine Database and international trial registers (to 19 June 2018). We also conducted a grey literature search and handsearched the reference lists of included studies and pertinent review articles.

SELECTION CRITERIA

For efficacy, we included randomised controlled trials (RCTs) on adults with a history of winter-type SAD who were free of symptoms at the beginning of the study. For adverse events, we planned to include non-randomised studies. Eligible studies compared a SGA versus another SGA, placebo, light therapy, psychological therapy, melatonin, agomelatine or lifestyle changes. We also intended to compare SGAs in combination with any of the comparator interventions versus placebo or the same comparator intervention as monotherapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and full-text publications, extracted data and assessed risk of bias of included studies. When data were sufficient, we conducted random-effects (Mantel-Haenszel) meta-analyses. We assessed statistical heterogeneity by calculating the Chi2 statistic and the Cochran Q. We used the I2 statistic to estimate the magnitude of heterogeneity. We assessed publication bias by using funnel plots.We rated the strength of the evidence using the system developed by the GRADE Working Group.

MAIN RESULTS

We identified 3745 citations after de-duplication of search results and excluded 3619 records during title and abstract reviews. We assessed 126 full-text papers for inclusion in the review, of which four publications (on three RCTs) providing data from 1100 people met eligibility criteria for this review. All three RCTs had methodological limitations due to high attrition rates.Overall, moderate-quality evidence indicates that bupropion XL is an efficacious intervention for prevention of recurrence of depressive episodes in people with a history of SAD (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.44 to 0.72; 3 RCTs, 1100 participants). However, bupropion XL leads to greater risk of headaches (moderate-quality evidence), insomnia and nausea (both low-quality evidence) when compared with placebo. Numbers needed to treat for additional beneficial outcomes (NNTBs) vary by baseline risks. For a population with a yearly recurrence rate of 30%, the NNTB is 8 (95% CI 6 to 12). For populations with yearly recurrence rates of 50% and 60%, NNTBs are 5 (95% CI 4 to 7) and 4 (95% CI 3 to 6), respectively.We could find no studies on other SGAs and no studies comparing SGAs with other interventions of interest, such as light therapy, psychological therapies, melatonin or agomelatine.

AUTHORS' CONCLUSIONS

Available evidence indicates that bupropion XL is an effective intervention for prevention of recurrence of SAD. Nevertheless, even in a high-risk population, three out of four people will not benefit from preventive treatment with bupropion XL and will be at risk for harm. Clinicians need to discuss with patients advantages and disadvantages of preventive SGA treatment, and might want to consider offering other potentially efficacious interventions, which might confer a lower risk of adverse events. Given the lack of comparative evidence, the decision for or against initiating preventive treatment of SAD and the treatment selected should be strongly based on patient preferences.Future researchers need to assess the effectiveness and risk of harms of SGAs other than bupropion for prevention of SAD. Investigators also need to compare benefits and harms of pharmacological and non-pharmacological interventions.

No evidence of seasonal variation in mild forms of depression

BACKGROUND AND OBJECTIVES

Seasonal Affective Disorder (SAD) is ubiquitous in popular culture and has influenced psychiatric diagnosis with the inclusion of the seasonal pattern modifier for the Major Depressive Episode in DSM. However, recent research has not supported the association of Major Depressive Episode with seasonal changes. The present study was conducted to determine if a seasonally-related pattern of occurrence of mild variants of depression could be demonstrated in a population-based study.

METHODS

This is a cross-sectional U.S. survey of adults who completed the PHQ-8 Depression Scale with mild depression defined using a PHQ-8 cut score and a second model based on the DSM-5 diagnosis, Depression with insufficient symptoms. Regression models were used to determine if either variant of mild depression was related to season, latitude, or measures of daylight hours.

RESULTS

Neither measure of mild depression was related to daylight hours or its proxy measures.

LIMITATIONS

Screening instruments for depression, even if consistent with DSM-5 diagnostic criteria, do not allow a formal diagnosis of depression or the exclusion of similar-appearing disorders. Current depression symptoms but not duration of depressive episode is measured.

CONCLUSIONS

Mild depression is not related to seasonal changes or proxy measures of light exposure. The findings cast doubt on light deficiency as a causal factor of depressive disorders, which underpins the inclusion of the seasonal pattern modifier in DSM-5 and light supplementation as a treatment modality.

Bright Light as a Personalized Precision Treatment of Mood Disorders

Background: The use of light for its antidepressant action dates back to the beginnings of civilization. Three decades ago, the use of bright-light therapy (BLT) for treating Seasonal Affective Disorder (SAD) was officially proposed. Since then, a growing scientific literature reports its antidepressant efficacy in both unipolar and bipolar disorders (BD), with or without seasonal patterns. This review aims to examine the management of BLT as a personalized and precision treatment in SAD, unipolar, and BD. Methods: We conducted a narrative review using Medline and Google Scholar databases up to June 2018. Results: BLT has physiological effects by resynchronizing the biological clock (circadian system), enhancing alertness, increasing sleep pressure (homeostatic system), and acting on serotonin, and other monoaminergic pathways. Effects of BLT on mood depend on several factors such as light intensity, wavelength spectrum, illumination duration, time of the day, and individual circadian rhythms. A growing body of evidence has been generated over the last decade about BLT evolving as an effective depression treatment not only to be used in SAD, but also in non-seasonal depression, with efficiency comparable to fluoxetine, and possibly more robust in patients with BD. The antidepressant action of BLT is fast (within 1-week) and safe, with the need in BD to protect against manic switch with mood stabilizers. Side effects might be nausea, diarrhea, headache, and eye irritation, and are generally mild and rare. This good safety profile may be of particular interest, especially in women during the perinatal period or for the elderly. The management of BLT needs to be clarified across mood disorders and future studies are expected to compare different dose-titration protocols, to validate its use as a maintenance treatment, and also to identify predictive biomarkers of response and tolerability. We propose clinical guidelines for BLT use in SAD, non-seasonal depression, and BD. Conclusions : BLT is an efficient antidepressant strategy in mono- or adjunct-therapy, that should be personalized according the unipolar or bipolar subtype, the presence or absence of seasonal patterns, and also regarding its efficacy and tolerability.

Adolescent depression: Study protocol for a randomized, controlled, double-blind multicenter parallel group trial of Bright Light Therapy in a naturalistic inpatient setting (DeLight)

BACKGROUND

Depressive disorders are among the most prominent health problems in youth. Even with the best available pharmacological and non-pharmacological treatments, remission rates are low. Without early treatment, depression in youth is associated with a high risk of symptom progression, chronicity, co-morbidity, and suicidal behavior. Thus, adolescent depression is a prime candidate for innovation in treatment. In depressive adults, meta-analytic evidence has proven that bright light therapy (BLT) is a potent low-threshold intervention, promising due to easy application, low side effects, and optimized compliance. In adolescents, studies with small samples show promising effects. This randomized controlled trial will examine the effectiveness of BLT in youth inpatients.

METHODS/DESIGN

In this randomized, controlled, double-blind multicenter parallel group trial, morning BLT is applied for four weeks in addition to treatment as usual (TAU) for depressed youth inpatients (daily morning exposure to bright light via light-emitting glasses, 10,000 lx, for 30 min) and will be compared to a control condition (placebo light treatment, red light, identical light glasses). The primary objective is to assess whether BLT reduces symptoms of depression in youth with greater effect compared to placebo light therapy. Secondary objectives are to examine the impact of BLT on responder status, application of antidepressant medication, and further depression-related symptoms (sleep, activity, quality of life, satisfaction with health, general psychopathology, alertness, and circadian function). N = 224 patients will be recruited in a naturalistic inpatient setting. A follow-up will be carried out after three and six months.

DISCUSSION

The study aims to discuss and evaluate BLT as an additive method supporting standardized clinical procedures dealing with severe to moderate depressive symptoms in youth.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00013188 . Registered on November 30, 2017.

Pharmacotherapy and nutritional supplements for seasonal affective disorders: a systematic review

INTRODUCTION

A seasonal affective disorder (SAD) is a subtype of unipolar and bipolar major depressive disorders. It is characterized by its annual recurrence of depressive episodes at a particular season, mostly seen in winter and is responsible for 10-20% of the prevalence of major depressive disorders. Some pathophysiological hypotheses, such as the phase delay and the monoamine depletion hypotheses, have been postulated but the exact cause has not been fully unraveled yet. Studies on treatment for SAD in the last decade are lacking. To tackle this chronic disease, attention needs to be drawn to the gaps in this research field.

AREAS COVERED

In this systematic review, the authors give a broad overview of the pharmacological therapy available for SAD. Also, nutritional substances fitting well with the postulated hypotheses are reviewed for the treatment and prevention of SAD. There is a specific focus on the quality of the currently performed studies.

EXPERT OPINION

Light therapy and fluoxetine are the only proven and effective acute treatment options for SAD, while bupropion is the only registered drug for prevention of SAD. This area of research is in dire need of valid large-scale and sufficiently reproducible randomized control trials.

Light therapy for older patients with non-seasonal depression: A systematic review and meta-analysis

BACKGROUND

Light therapy has become an increasingly common treatment for adults with depression, yet the role of light therapy for non-seasonal depression among older adults remains unclear.

OBJECTIVE

This meta-analysis sought to evaluate the effectiveness of light therapy among older patients with non-seasonal depression.

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science, CNKI and CBM from the inception of each database to May 2017. Two researchers conducted the literature screening, data extraction, and methodological quality assessment independently. We used the Cochrane Collaboration's bias assessment tool to evaluate the risk of bias for included studies, and Review Manager 5.2.3 Software for the meta-analysis.

RESULTS

Six trials with a total of 359 patients were included, and five studies were assessed as being of low risk for bias. We evaluated the effect of light therapy on depression by the reduction of depressive symptoms (SMD = 0.45; 95% CI= [0.14, 0.75]). The subgroup analysis did not find significant moderating effects of depression with intervention intensity, light type, measuring scale or intervention duration.

LIMITATIONS

Most of the study samples were not representative of the larger population of adults and therefore caution should be used when interpreting the findings.

CONCLUSIONS

Light therapy has a positive effect on geriatric non-seasonal depression. Studies with larger sample sizes are needed to confirm the curative effect of light therapy in the future.

Photoperiod-Induced Neuroplasticity in the Circadian System

Seasonal changes in light exposure have profound effects on behavioral and physiological functions in many species, including effects on mood and cognitive function in humans. The mammalian brain's master circadian clock, the suprachiasmatic nucleus (SCN), transmits information about external light conditions to other brain regions, including some implicated in mood and cognition. Although the detailed mechanisms are not yet known, the SCN undergoes highly plastic changes at the cellular and network levels under different light conditions. We therefore propose that the SCN may be an essential mediator of the effects of seasonal changes of day length on mental health. In this review, we explore various forms of neuroplasticity that occur in the SCN and other brain regions to facilitate seasonal adaptation, particularly altered phase distribution of cellular circadian oscillators in the SCN and changes in hypothalamic neurotransmitter expression.

Precision Light for the Treatment of Psychiatric Disorders

Circadian timekeeping can be reset by brief flashes of light using stimulation protocols thousands of times shorter than those previously assumed to be necessary for traditional phototherapy. These observations point to a future where flexible architectures of nanosecond-, microsecond-, and millisecond-scale light pulses are compiled to reprogram the brain's internal clock when it has been altered by psychiatric illness or advanced age. In the current review, we present a chronology of seminal experiments that established the synchronizing influence of light on the human circadian system and the efficacy of prolonged bright-light exposure for reducing symptoms associated with seasonal affective disorder. We conclude with a discussion of the different ways that precision flashes could be parlayed during sleep to effect neuroadaptive changes in brain function. This article is a contribution to a special issue on Circadian Rhythms in Regulation of Brain Processes and Role in Psychiatric Disorders curated by editors Shimon Amir, Karen Gamble, Oliver Stork, and Harry Pantazopoulos.

Genetic Factors Affecting Seasonality, Mood, and the Circadian Clock

In healthy humans, seasonality has been documented in psychological variables, chronotype, sleep, feeding, metabolic and autonomic function, thermoregulation, neurotransmission, and hormonal response to stimulation, thus representing a relevant factor to account for, especially when considering the individual susceptibility to disease. Mood is largely recognized as one of the central aspects of human behavior influenced by seasonal variations. This historical notion, already mentioned in ancient medical reports, has been recently confirmed by fMRI findings, which showed that seasonality in human cognitive brain functions may influence affective control with annual variations. Thus, seasonality plays a major role in mood disorders, affecting psychopathology, and representing the behavioral correlate of a heightened sensitivity to factors influencing circannual rhythms in patients. Although the genetic basis of seasonality and seasonal affective disorder (SAD) has not been established so far, there is growing evidence that factors affecting the biological clock, such as gene polymorphisms of the core clock machinery and seasonal changes of the light-dark cycle, exert a marked influence on the behavior of patients affected by mood disorders. Here we review recent findings about the effects of individual gene variants on seasonality, mood, and psychopathological characteristics.

Controlled trial evaluation of exposure duration to negative air ions for the treatment of seasonal affective disorder

This study evaluated the effectiveness of 30 or 60min of daily exposure to high-density or to zero-density (placebo condition) negative air ions over 18 days on the symptoms of seasonal affective disorder (SAD) in 40 participants under controlled laboratory conditions. Exposure to high-density negative air ions was superior to zero-density negative air ions in alleviating depression and the atypical symptoms of SAD. Also, more subjects in the high-density negative air ions groups met two different clinical response criteria than did those in the zero-density groups. Within the high density treatment group, both the short and long daily exposure reduced SAD symptoms. Exposure to negative air ions produced no negative side effects, and no ozone was produced by the ion generators. In both the high-density negative air ions and zero-density negative air ions groups, a significant placebo effect was found for most clinical measures. Finally, for the high-density negative air ion groups, subjects with a morningness chronotype responded better to treatment with high-density negative air ions than did those with an eveningness chronotype.

Seasonal mood changes in patients with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is frequently associated with mood disorders. However, to date, the co-occurrence of OCD with seasonal affective disorder (SAD) has not been investigated. We have aimed to estimate the prevalence of seasonal mood changes in patients with OCD and explore the contribution of seasonality in mood to the severity of OCD. The Seasonal Pattern Assessment Questionnaire (SPAQ), the Yale-Brown Obsession and Compulsion Scale (Y-BOCS), the Hamilton Depression Rating Scale-17 Items (HDRS-17), and the Beck Anxiety Inventory (BAI) were administered to patients with OCD (n=104) and controls (n=125). The degree of seasonality was measured by the Global Seasonality Score (GSS) calculated from the SPAQ. SAD and subsyndromal seasonal affective disorder (S-SAD) were significantly more prevalent in patients with OCD (53%, n=55) than controls (25%, n=31). When patients were assessed in the season in which SAD occurs, depression and compulsions (but not obsessions, OCD or anxiety) were more severe than those assessed in a season during which SAD does not occur. SAD frequently co-occurs with OCD and, given this co-occurrence, depression symptoms in some patients with OCD might be expected to vary on a seasonal basis.

The extended evolutionary synthesis and addiction: the price we pay for adaptability

Humans are more likely to become addicted and to stay addicted than are other animals. This chapter is a neurobiological and molecular review of addiction and the cooccurring traits and psychiatric disorders from the perspective of the Extended Evolutionary Synthesis (EES). Addiction is an example of pleiotropy as many common haplotypes that are associated with individual differences in vulnerability to substance dependence express a variety of important brain-based phenotypes such as neuroadaptive processes. The neurochemical mechanisms of addiction are shared with behavioral flexibility and the ability to innovate, which are hallmark features of our species. The dopaminergic system provides a link between addiction and the cooccurring traits and psychiatric disorders evident in the shared genetic profile. A hypofunctioning dopaminergic system is also a common characteristic feature of addiction and the cooccurring traits and psychiatric disorders. Epigenetics allows for environmental factors to create lasting and heritable phenotypic changes enabling rapid adaptation to an environment. Addiction "high-jacks" this system as well as the neurochemical mechanisms that control flexibility and innovation and is, thus, the price we pay for adaptability.

Plasma Phosphatidylethanolamine and Triacylglycerol Fatty Acid Concentrations are Altered in Major Depressive Disorder Patients with Seasonal Pattern

Disturbances in peripheral and brain lipid metabolism, including the omega-3 fatty acid docosahexaenoic acid (DHA), have been reported in major depressive disorder (MDD). However, these changes have yet to be confirmed in MDD with seasonal pattern (MDD-s), a subtype of recurrent MDD. The present exploratory study quantified plasma plasmalogen and diacyl-phospholipid species, and fatty acids within total phospholipids, cholesteryl esters, triacylglycerols and free fatty acids in non-medicated MDD-s participants (n = 9) during euthymia in summer or fall, and during depression in winter in order to screen for potential high sensitivity lipid biomarkers. Triacylglycerol alpha-linolenic acid concentration was significantly decreased, and myristoleic acid concentration was significantly increased, during winter depression compared to summer-fall euthymia. 1-stearyl-2-docosahexaenoyl-sn-glycero-3-phosphoethanolamine, a diacyl-phospholipid containing stearic acid and DHA, was significantly decreased in winter depression. Concentrations of cholesteryl ester oleic acid and several polyunsaturated fatty acids between summer/fall and winter increased in proportion to the increase in depressive symptoms. The observed changes in lipid metabolic pathways in winter-type MDD-s offer new promise for lipid biomarker development.

Neurotransmitter Switching in the Developing and Adult Brain

Neurotransmitter switching is the gain of one neurotransmitter and the loss of another in the same neuron in response to chronic stimulation. Neurotransmitter receptors on postsynaptic cells change to match the identity of the newly expressed neurotransmitter. Neurotransmitter switching often appears to change the sign of the synapse from excitatory to inhibitory or from inhibitory to excitatory. In these cases, neurotransmitter switching and receptor matching thus change the polarity of the circuit in which they take place. Neurotransmitter switching produces up or down reversals of behavior. It is also observed in response to disease. These findings raise the possibility that neurotransmitter switching contributes to depression, schizophrenia, and other illnesses. Many early discoveries of the single gain or loss of a neurotransmitter may have been harbingers of neurotransmitter switching.

Patients' Experience of Winter Depression and Light Room Treatment

Background. There is a need for more knowledge on the effects of light room treatment in patients with seasonal affective disorder and to explore patients' subjective experience of the disease and the treatment. Methods. This was a descriptive and explorative study applying qualitative content analysis. A purposeful sample of 18 psychiatric outpatients with a major depressive disorder with a seasonal pattern and a pretreatment score ≥12 on the 9-item Montgomery-Åsberg Depression self-rating scale was included (10 women and 8 men, aged 24-65 years). All patients had completed light room treatment (≥7/10 consecutive weekdays). Data was collected two weeks after treatment using a semistructured interview guide. Results. Patients described a clear seasonal pattern and a profound struggle to adapt to seasonal changes during the winter, including deterioration in sleep, daily rhythms, energy level, mood, activity, and cognitive functioning. Everyday life was affected with reduced work capacity, social withdrawal, and disturbed relations with family and friends. The light room treatment resulted in a radical and rapid improvement in all the major symptoms with only mild and transient side effects. Discussion. The results indicate that light room treatment is essential for some patients' ability to cope with seasonal affective disorder.

A multicenter randomized controlled trial for bright light therapy in adults with intellectual disabilities and depression: Study protocol and obstacle management

Due to the limited cognitive and communicative abilities of adults with intellectual disabilities (ID), current treatment options for depression are often limited to lifestyle changes and pharmacological treatment. Bright light therapy (BLT) is an effective intervention for both seasonal and non-seasonal depression in the general population. BLT is an inexpensive, easy to carry out intervention with minimal side effects. However, knowledge on its anti-depressant effect in adults with ID is lacking. Obstacles in realizing a controlled intervention study in this particular study population may have contributed to this lack. To study the effect of BLT on depression in this population, it is necessary to successfully execute a multicenter randomized controlled trial (RCT). Therefore, the study protocol and the management of anticipated obstacles regarding this trial are presented.