Bright light treatment of depression for older adults [ISRCTN55452501]

A Review of Therapeutics for Treatment-Resistant Depression in the Older Adult

One-third of older adults with depression meet criteria for treatment resistance, typically defined as a lack of response to two or more adequate trials of an antidepressant. Treatment resistance contributes to an unfavorable prognosis, compromised medical outcomes, heightened disability, accelerated cognitive decline, and an elevated risk of developing dementia. Despite this significant morbidity, evidence is sparse for how to proceed with treatment in this population. Non-pharmacologic therapy (e.g., diet, psychotherapy) can be utilized as adjunctive therapy, despite little published evidence of benefit, given that the risks are low. Pharmacotherapy trials in the treatment-resistant late-life depression population lack strong methods and external validity; however, the use of venlafaxine as monotherapy and add-on therapy, as well as lithium, bupropion, or aripiprazole as add-on therapy to standard antidepressant therapy, have enough evidence that a trial with appropriate monitoring is a prudent strategy. Electroconvulsive therapy remains a well-studied safe therapy, especially when used as maintenance treatment once an initial cycle is completed but is traditionally underutilized in the treatment-resistant late-life depression population. Ensuring non-pharmacologic and pharmacologic strategies are optimized and given a sufficient trial in those with treatment-resistant late-life depression is the best we can do for this vulnerable population.

Illuminating the way: the role of bright light therapy in the treatment of depression

INTRODUCTION

Despite the growing number of different therapeutic options, treatment of depression is still a challenge. A broader perspective reveals the benefits of bright light therapy (BLT). It stimulates intrinsically photosensitive retinal ganglion cells, which induces a complex cascade of events, including alterations in melatonergic, neurotrophic, GABAergic, glutamatergic, noradrenergic, serotonergic systems, and HPA axis, suggesting that BLT effects expand beyond the circadian pacemaker.

AREAS COVERED

In this review, the authors present and discuss recent data of BLT in major depressive disorder, non-seasonal depression, bipolar depression or depressive phase of bipolar disorder, and seasonal affective disorder, as well as in treatment-resistant depression (TRD). The authors further highlight BLT effects in various depressive disorders compared to placebo and report data from several studies suggesting a response to BLT in TRD. Also, the authors report data showing that BLT can be used both as a monotherapy or in combination with other pharmacological treatments.

EXPERT OPINION

BLT is an easy-to-use and low-budget therapy with good tolerability. Future studies should focus on clinical and biological predictors of response to BLT, on defining specific populations which may benefit from BLT and establishing treatment protocols regarding timing, frequency, and duration of BLT.

Actigraphically measured psychomotor slowing in depression: systematic review and meta-analysis

Psychomotor slowing is a key feature of depressive disorders. Despite its great clinical importance, the pathophysiology and prevalence across different diagnoses and mood states are still poorly understood. Actigraphy allows unbiased, objective, and naturalistic assessment of physical activity as a marker of psychomotor slowing. Yet, the true effect-sizes remain unclear as recent, large systematic reviews are missing. We conducted a novel meta-analysis on actigraphically measured slowing in depression with strict inclusion and exclusion criteria for diagnosis ascertainment and sample duplications. Medline/PubMed and Web-of-Science were searched with terms combining mood-keywords and actigraphy-keywords until September 2021. Original research measuring actigraphy for ⩾24 h in at least two groups of depressed, remitted, or healthy participants and applying operationalized diagnosis was included. Studies in somatically ill patients, N < 10 participants/group, and studies using consumer-devices were excluded. Activity-levels between groups were compared using random-effects models with standardized-mean-differences and several moderators were examined. In total, 34 studies (n = 1804 patients) were included. Patients had lower activity than controls [standardized mean difference (s.m.d.) = -0.78, 95% confidence interval (CI) -0.99 to -0.57]. Compared to controls, patients with unipolar and bipolar disorder had lower activity than controls whether in depressed (unipolar: s.m.d. = -0.82, 95% CI -1.07 to -0.56; bipolar: s.m.d. = -0.94, 95% CI -1.41 to -0.46), or remitted/euthymic mood (unipolar: s.m.d. = -0.28, 95% CI -0.56 to 0.0; bipolar: s.m.d. = -0.92, 95% CI -1.36 to -0.47). None of the examined moderators had any significant effect. To date, this is the largest meta-analysis on actigraphically measured slowing in mood disorders. They are associated with lower activity, even in the remitted/euthymic mood-state. Studying objective motor behavior via actigraphy holds promise for informing screening and staging of affective disorders.

"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.

Light therapy in non-seasonal depression: An update meta-analysis

The effect of light therapy in treating seasonal affective disorder has been demonstrated amongst previous studies. However, the effect of light therapy in treating non-seasonal depression remains unclear. This meta-analysis aimed to determine the efficacy of light therapy in non-seasonal depression. We searched for randomized controlled trials (RCTs) in the PubMed, Web of Science, Chinese National Knowledge Infrastructure, and Chinese Biomedical Database up to February 2020. The pooled post-trial standardized mean difference in depression scores with corresponding 95% confidence intervals was calculated to evaluate the efficacy of light therapy in non-seasonal depression. A total of 23 RCTs with 1120 participants were included. The meta-analysis demonstrated the light therapy was significantly more effective than comparative treatments. Subgroup analyses revealed that none of the factors explained the significantly heterogeneity. Light therapy has a statistically significant mild to moderate treatment effect in reducing depressive symptoms, can be used as a clinical therapy in treating non-seasonal depression. But the quality of evidence is still low, more well-designed studies with larger sample size and high quality are needed to confirm the efficiency of light therapy in treating non-seasonal depression.

Dynamic LED-light versus static LED-light for depressed inpatients: study protocol for a randomised clinical study

INTRODUCTION

Retrospective studies conducted in psychiatric inpatient wards have shown a relation between the intensity of daylight in patient rooms and the length of stay, pointing to an antidepressant effect of ambient lighting conditions. Light therapy has shown a promising antidepressant effect when administered from a light box. The emergence of light-emitting diode (LED) technology has made it possible to build luminaires into rooms and to dynamically mimic the spectral and temporal distribution of daylight. The objective of this study is to investigate the antidepressant efficacy of a newly developed dynamic LED-lighting system installed in an inpatient ward.

METHODS AND ANALYSIS

In all, 150 inpatients with a major depressive episode, as part of either a major depressive disorder or as part of a bipolar disorder, will be included. The design is a two-arm 1:1 randomised study with a dynamic LED-lighting arm and a static LED-lighting arm, both as add-on to usual treatment in an inpatient psychiatric ward. The primary outcome is the baseline adjusted score on the 6-item Hamilton Depression Rating Scale at week 3. The secondary outcomes are the mean score on the Suicidal Ideation Attributes Scale at week 3, the mean score on the 17-item Hamilton Depression Rating Scale at week 3 and the mean score on the World Health Organisation Quality of Life-BREF (WHOQOL-BREF) at week 3. The spectral distribution of daylight and LED-light, with a specific focus on light mediated through the intrinsically photosensitive retinal ganglion cells, will be measured. Use of light luminaires will be logged. Assessors of Hamilton Depression Rating Scale scores and data analysts will be blinded for treatment allocation. The study was initiated in May 2019 and will end in December 2021.

ETHICS AND DISSEMINATION

No ethical issues are expected. Results will be published in peer-reviewed journals, disseminated electronically and in print and presented at symposia.

TRIAL REGISTRATION NUMBER

NCT03821506; Pre-results.

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

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

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.

Neurobiological Mechanisms of Stress Resilience and Implications for the Aged Population

BACKGROUND

Stress is a common reaction to an environmental adversity, but a dysregulation of the stress response can lead to psychiatric illnesses such as major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and anxiety disorders. Yet, not all individuals exposed to stress will develop psychiatric disorders; those with enhanced stress resilience mechanisms have the ability to adapt successfully to stress without developing persistent psychopathology. Notably, the potential to enhance stress resilience in at-risk populations may prevent the onset of stress-induced psychiatric disorders. This novel idea has prompted a number of studies probing the mechanisms of stress resilience and how it can be manipulated.

METHODS

Here, we review the neurobiological factors underlying stress resilience, with particular focus on the serotoninergic (5-HT), glutamatergic, and γ-Aminobutyric acid (GABA) systems, as well as the hypothalamic-pituitary axis (HPA) in rodents and in humans. Finally, we discuss stress resiliency in the context of aging, as the likelihood of mood disorders increases in older adults.

RESULTS

Interestingly, increased resiliency has been shown to slow aging and improved overall health and quality of life. Research in the neurobiology of stress resilience, particularly throughout the aging process, is a nascent, yet, burgeoning field.

CONCLUSION

Overall, we consider the possible methods that may be used to induce resilient phenotypes, prophylactically in at-risk populations, such as in military personnel or in older MDD patients. Research in the mechanisms of stress resilience may not only elucidate novel targets for antidepressant treatments, but also provide novel insight about how to prevent these debilitating disorders from developing.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

Light therapy is a known treatment for patients with seasonal affective disorder. However, the efficacy of light therapy in treating patients with non-seasonal depression remains inconclusive.

AIMS

To provide the current state of evidence for efficacy of light therapy in non-seasonal depressive disorders.

METHOD

Systematic review of randomised controlled trials (RCTs) was conducted by searching MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL from their inception to September 2015. Study selection, data abstraction and risk of bias assessment were independently conducted in duplicate. Meta-analyses were performed to provide a summary statistic for the included RCTs. The reporting of this systematic review follows the PRISMA guidelines.

RESULTS

A meta-analysis including 881 participants from 20 RCTs demonstrated a beneficial effect of light therapy in non-seasonal depression (standardised mean difference in depression score -0.41 (95% CI -0.64 to -0.18)). This estimate was associated with significant heterogeneity (I2=60%, P=0.0003) that was not sufficiently explained by subgroup analyses. There was also high risk of bias in the included trials limiting the study interpretation.

CONCLUSIONS

The overall quality of evidence is poor due to high risk of bias and inconsistency. However, considering that light therapy has minimal side-effects and our meta-analysis demonstrated that a significant proportion of patients achieved a clinically significant response, light therapy may be effective for patients with non-seasonal depression and can be a helpful additional therapeutic intervention for depression.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Light therapy for better mood and insulin sensitivity in patients with major depression and type 2 diabetes: a randomised, double-blind, parallel-arm trial

BACKGROUND

Major depression and type 2 diabetes often co-occur. Novel treatment strategies for depression in type 2 diabetes patients are warranted, as depression in type 2 diabetes patients is associated with poor prognosis and treatment results. Major depression and concurrent sleep disorders have been related to disturbances of the biological clock. The biological clock is also involved in regulation of glucose metabolism by modulating peripheral insulin sensitivity. Light therapy has been shown to be an effective antidepressant that 'resets' the biological clock. We here describe the protocol of a study that evaluates the hypothesis that light therapy improves mood as well as insulin sensitivity in patients with a major depressive episode and type 2 diabetes.

METHODS/DESIGN

This study is a randomised, double-blind, parallel-arm trial in 98 participants with type 2 diabetes and a major depressive episode, according to DSM-IV criteria. We will assess whether light therapy improves depressive symptoms and insulin sensitivity, our primary outcome measures, and additionally investigate whether these effects are mediated by restoration of the circadian rhythmicity, as measured by sleep and hypothalamic-pituitary-adrenal axis activity. Participants will be randomly allocated to a bright white-yellowish light condition or dim green light condition. Participants will undergo light therapy for half an hour every morning for 4 weeks at home. At several time points, namely before the start of light therapy, during light therapy, after completion of 4 weeks of light therapy and after 4 weeks follow-up, several psychometrical, psychophysiological and glucometabolic measures will be performed.

DISCUSSION

If light therapy effectively improves mood and insulin sensitivity in type 2 diabetes patients with a major depressive episode, light therapy may be a valuable patient friendly addition to the currently available treatment strategies. Additionally, if our data support the role of restoration of circadian rhythmicity, such an observation may guide further development of chronobiological treatment strategies in this patient population.

TRIAL REGISTRATION

The Netherlands Trial Register (NTR) NTR4942 . Registered 13 January 2015.

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Senior Living Environments: Evidence-Based Lighting Design Strategies

OBJECTIVE:

To review from an architectural lighting perspective the effects of indoor lighting on the health and well-being of people in senior living environments.

BACKGROUND:

The role of circadian rhythms in people with chronic disorders continues to be a focus of laboratory research and clinical trials. Beneficial, evidence-based indoor lighting design strategies are being considered for senior living environments, particularly for residents who have limited access to natural bright light.

METHODS:

Articles published 2002–2012 reporting the results of prospective, randomized, controlled clinical trials (RCTs) were accessed using the U.S. National Library of Medicine PubMed site using the following search terms: “light, sleep, circadian, randomized, controlled, nursing home” and “light, sleep, circadian, randomized, controlled, elderly.”

RESULTS:

The search resulted in 48 citations, of which 18 meet our pre-search criteria. Data from these RCTs indicate options such as programmable, 24-hour lighting algorithms that may involve light intensity, lighting duration, spectra (wavelength) and lighting timing sequences

CONCLUSIONS:

Valid and actionable data are available about circadian rhythms, sleep, and human health and well-being that can inform the design of lighting for long-term care. Evidence-based architectural design of a 24-hour light/dark environment for residents may mitigate symptoms of circadian disruption; evidence-based management of darkness is as important as evidence-based management of light. Further research is needed into the long-term circadian health needs of night staff members in order to understand the effects of shift work while, at the same time providing the highest level of care.

Efficacy of agomelatine in major depressive disorder: meta-analysis and appraisal

Agomelatine is the first approved antidepressant that mediates its activity through the melatoninergic pathway rather than the monoaminergic system. This meta-analysis aims to summarize an up-to-date report on the efficacy of agomelatine in major depressive disorder. Archives of published results in PubMed, CINAHL, Cochrane Library, EMBASE and PsycINFO databases were searched for randomized double-blind trials comparing agomelatine against placebo or antidepressant in major depressive disorder. Change in severity of depression as a result of intervention was the main outcome measure. Data necessary to compute the standardized mean difference (SMD) of this outcome and additional sample parameters that were likely to influence the main outcome were extracted for each selected studies. Summary effect sizes of various groups and subgroups were computed from SMDs between agomelatine and control (placebo or antidepressants) arms. There were nine trials involving 3943 severe cases of depression on agomelatine (n=2390) and either placebo (n=689) or antidepressants (n=864). Agomelatine (n=1274) stood superior to placebo (n=689) by a small margin (SMD -0.26, p=3.48×10-11) and the superiority of agomelatine (n=834, dose ≥ 25 mg/d) over antidepressants (paroxetine, fluoxetine, sertraline, venlafaxine; n=864) was even smaller (SMD -0.11, p=0.02). Although there is evidence of the superiority of agomelatine over placebo and selected antidepressants, it is questionable whether the magnitude of effect size is clinically significant and sample characteristics are relevant to the general patient population with major depressive disorder.

Complex interaction of circadian and non-circadian effects of light on mood: shedding new light on an old story

In addition to its role in vision, light exerts strong effects on behavior. Its powerful role in the modulation of mood is well established, yet remains poorly understood. Much research has focused on the effects of light on circadian rhythms and subsequent interaction with alertness and depression. The recent discovery of a third photoreceptor, melanopsin, expressed in a subset of retinal ganglion cells, allows major improvement of our understanding of how photic information is processed. Light affects behavior in two ways, either indirectly through the circadian timing system, or directly through mechanisms that are independent of the circadian system. These latter effects have barely been studied in regard to mood, but recent investigations on the direct effects of light on sleep and alertness suggest additional pathways through which light could influence mood. Based on our recent findings, we suggest that light, via melanopsin, may exert its antidepressant effect through a modulation of the homeostatic process of sleep. Further research is needed to understand how these mechanisms interplay and how they contribute to the photic regulation of mood. Such research could improve therapeutic management of affective disorders and influence the management of societal lighting conditions.

Bright light treatment for high-anxious young adults: a randomized controlled pilot study

BACKGROUND

Available treatments for anxiety have limitations and/or side effects. The aim of this study was to examine the influence of bright light exposure as a treatment in high-anxious young adults.

METHODS

In an acute exposure study, participants (n = 33) were randomly assigned to 45  min of (1) bright light or (2) placebo. Participants then performed a 5-week study (n = 29). Following a 1-week baseline, participants were randomly assigned to 4 weeks of daily exposure to either (1) bright light (45  min/day) or (2) placebo treatment, initiated ≤1 hr after awakening. Before and after the experiment, clinical ratings were conducted with the Hamilton Anxiety Scale (HAM-A), Hamilton Depression Scale, and Clinical Global Impressions scale. Following each week, blood pressure, anxiety (Spielberger State-Trait Anxiety Inventory Y1), depression, mood, sleep, and side effects were assessed.

RESULTS

No significant treatment effect was found in the acute exposure study. Likewise, in the 5-week study, no significant treatment effect was found. However, bright light elicited marginally greater reductions in psychic symptoms of the HAM-A (P = .06) and other measures.

CONCLUSIONS

This pilot study provides little compelling evidence for an anxiolytic effect of bright light in high-anxious young adults.

Cerebral microbleeds and symptom severity of post-stroke depression: a magnetic resonance imaging study

BACKGROUND

Cerebral microbleeds (CMBs) are common in stroke survivors, although their clinical significance in the development of psychiatric conditions following stroke remains unknown. This study examines the association between post-stroke depression (PSD) symptom severity and CMBs.

METHODS

Amongst the 4088 patients with acute ischemic stroke who had been admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong, between December 2004 and May 2009, 994 patients were recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all 994 patients and made a diagnosis of PSD three months after the index stroke. PSD symptom severity was assessed with the 15-item Geriatric Depression Scale (GDS). Seventy-eight patients were found to have PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging (MRI).

RESULTS

Seventy-eight patients (7.8%) had PSD. CMBs were identified in 20 PSD patients. Relative to the no-CMB group, the mean GDS score of patients with lobar CMBs was significantly higher (12.6±2.6 versus 10.4±2.5, p=0.01 after adjusting for age, sex, global cognitive functions, neurological deficits and white matter hyperintensities).

LIMITATIONS

Patients with more severe stroke, those who died before the three-month follow-up and those who became depressed later were excluded, as were those unable to give their consent due to dementia or aphasia. These selection biases may limit the generalizability of the findings.

CONCLUSIONS

The results suggest that lobar CMBs may contribute to PSD symptom severity. The importance of CMBs in the pathogenesis of other psychiatric disorders in stroke survivors and other patient populations warrants further investigation.

Bright light treatment as add-on therapy for depression in 28 adolescents: a randomized trial

BACKGROUND

In the last decade, a significant incidence of depression in the younger population has been observed. Bright light therapy, an effective therapeutic option for depressed adults, could also provide safe, economical, and effective rapid recovery in adolescents.

METHOD

The randomized trial included 28 inpatients (18 females and 10 males) between 14 and 17 years old with depressive complaints. The study was conducted between February and December of 2010 in Rodewisch, Germany. Half of the patients (n = 14) first received placebo (50 lux) 1 hour a day in the morning from 9:00 am to 10:00 am for 1 week and then received bright light therapy (2,500 lux) for 1 week in the morning from 9:00 am to 10:00 am. The other half (n = 14) first received bright light therapy and then received placebo. Patients were encouraged to continue ongoing treatment (fluoxetine 20 mg/day and 2 sessions of psychotherapy/week) because there were no changes in medication/dosage and psychotherapy since 1 month before the 4-week study period. For assessment of depressive symptoms, the Beck Depression Inventory (BDI) was administered 1 week before and 1 day before placebo treatment, on the day between placebo and bright light treatment, and on the day after and 1 week after bright light treatment. Saliva samples of melatonin and cortisol were collected at 8:00 am and 8:00 pm 1 week before and 1 day before placebo treatment, on the day between placebo and bright light treatment, on the day after bright light treatment, and 1 week after bright light treatment and were assayed for melatonin and cortisol to observe any change in circadian timing.

RESULTS

The BDI scores improved significantly (P = .015). The assays of saliva showed significant differences between treatment and placebo for evening melatonin (P = .040). No significant adverse reactions were observed.

CONCLUSIONS

Antidepressant response to bright light treatment in this age group was statistically superior to placebo.

TRIAL REGISTRATION

World Health Organization International Clinical Trials Registry Platform identifier: DRKS00003309.

Louis EK. Illuminating rationale and uses for light therapy

Light therapy is increasingly applied in a variety of sleep medicine and psychiatric conditions including circadian rhythm sleep disorders, seasonal affective disorder, and dementia. This article reviews the neural underpinnings of circadian neurobiology crucial for understanding the influence of light therapy on brain function, common mood and sleep disorders in which light therapy may be effectively used, and applications of light therapy in clinical practice.

Circadian rhythm disturbances in depression

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00332670.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines

A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.

Advances in the treatment of geriatric depression

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

Bright green light treatment of depression for older adults [ISRCTN69400161]

BACKGROUND

Bright white light has been successfully used for the treatment of depression. There is interest in identifying which spectral colors of light are the most efficient in the treatment of depression. It is theorized that green light could decrease the intensity duration of exposure needed. Late Wake Treatment (LWT), sleep deprivation for the last half of one night, is associated with rapid mood improvement which has been sustained by light treatment. Because spectral responsiveness may differ by age, we examined whether green light would provide efficient antidepressant treatment in an elder age group.

METHODS

We contrasted one hour of bright green light (1,200 Lux) and one hour of dim red light placebo (<10 Lux) in a randomized treatment trial with depressed elders. Participants were observed in their homes with mood scales, wrist actigraphy and light monitoring. On the day prior to beginning treatment, the participants self-administered LWT.

RESULTS

The protocol was completed by 33 subjects who were 59 to 80 years old. Mood improved on average 23% for all subjects, but there were no significant statistical differences between treatment and placebo groups. There were negligible adverse reactions to the bright green light, which was well tolerated.

CONCLUSION

Bright green light was not shown to have an antidepressant effect in the age group of this study, but a larger trial with brighter green light might be of value.