Efficacy of light therapy for perinatal depression: a review

Understanding and treating postpartum depression: a narrative review

Postpartum depression (PPD) is an increasingly prevalent but still poorly characterized disorder. Causal and modulating factors include hormones fluctuations, such as estrogen, progesterone, and allopregnolone, pathways imbalances, such as oxytocin and kynurenine, chronobiological factors, and brain imaging alterations. Treatment may differ from the traditional major depression management, while selective serotonin reuptake inhibitors such as sertraline are commonly used and suggested by guidelines, neurosteroids such as brexanolone and the more convenient zuranolone have been recently approved. Newer neurosteroids such as ganaxolone, valaxanolone, and lysaxanolone are currently under development, but also esketamine and psychedelics are promising potential treatments. Other somatic treatments including brain stimulation techniques and light therapy also showed benefit. PPD is therefore increasingly understood as, at least partially, independent from major depressive disorder. Specific and individualized treatments including pharmacological and non-pharmacological therapies are progressively being introduced in the routine clinical practice.

Perinatal Depression and the Role of Synaptic Plasticity in Its Pathogenesis and Treatment

Emerging evidence indicates that synaptic plasticity is significantly involved in the pathophysiology and treatment of perinatal depression. Animal models have demonstrated the effects of overstimulated or weakened synapses in various circuits of the brain in causing affective disturbances. GABAergic theory of depression, stress, and the neuroplasticity model of depression indicate the role of synaptic plasticity in the pathogenesis of depression. Multiple factors related to perinatal depression like hormonal shifts, newer antidepressants, mood stabilizers, monoamine systems, biomarkers, neurotrophins, cytokines, psychotherapy and electroconvulsive therapy have demonstrated direct and indirect effects on synaptic plasticity. In this review, we discuss and summarize the various patho-physiology-related effects of synaptic plasticity in depression. We also discuss the association of treatment-related aspects related to psychotropics, electroconvulsive therapy, neuromodulation, psychotherapy, physical exercise and yoga with synaptic plasticity in perinatal depression. Future insights into newer methods of treatment directed towards the modulation of neuroplasticity for perinatal depression will be discussed.

Treating postpartum insomnia: a three arm randomised controlled trial of cognitive behavioural therapy and light dark therapy

BACKGROUND

Insomnia symptoms are common during the postpartum period, yet interventions remain scarce. This trial aimed to simultaneously examine the efficacy of cognitive behavioural therapy (CBT) and light dark therapy (LDT), targeting different mechanisms, against treatment-as-usual (TAU), in reducing maternal postpartum insomnia symptoms.

METHODS

This three-arm randomised controlled trial recruited from the general community in Australia. Nulliparous females 4-12 months postpartum with self-reported insomnia symptoms [Insomnia Severity Index (ISI) scores >7] were included; severe medical/psychiatric conditions were excluded. Participants were randomised 1:1:1 to CBT, LDT, or TAU stratified by ISI (< or ⩾14) and infant age (< or ⩾8 months). Participants and principal investigators were unblinded. Six-week interventions were delivered via digital materials and telephone. The primary outcome was insomnia symptoms (ISI), assessed pre-, midpoint-, post- (primary endpoint), and one-month post-intervention. Analyses were intention-to-treat using latent growth models.

RESULTS

114 participants (CBT = 39, LDT = 36, TAU = 39; Mage = 32.20 ± 4.62 years) were randomised. There were significantly greater reductions in ISI scores in CBT and LDT (effect sizes -2.01 and -1.52 respectively, p < 0.001) from baseline to post-intervention compared to TAU; improvements were maintained at follow-up. Similar effects were observed for self-reported sleep disturbance. There were greater reductions in fatigue in CBT (effect size = 0.85, p < 0.001) but not LDT (p = 0.11) compared to TAU. Changes in sleepiness, depression, and anxiety were non-significant compared to TAU (all p > 0.08). Four participants (11%) in the LDT group reported headaches, dizziness, or nausea; no others reported adverse events.

CONCLUSIONS

Therapist-assisted CBT and LDT were feasible during the first postpartum year; data at post-intervention and 1-month follow-up support their safety and efficacy in reducing postpartum insomnia symptoms.

Symptomatology in 1,112 women screened positive and negative using the Edinburgh postnatal depression scale (EPDS): longitudinal observations from the first trimester to 6 weeks postpartum of a Chinese cohort

PURPOSE

To compare the characteristics of depression-related symptoms identified by individual EPDS items in women who screened positive and negative, and to describe the occurrence of thoughts of self-harm in these women.

METHODS

Based on a Chinese cohort of 1,112 women, scores on each EPDS item were analyzed at 7 time points from the first trimester to 6 weeks postpartum. Scores greater than 0 indicated the presence of symptoms, and higher scores indicated more severe symptoms. We defined the most frequent, serious and important symptoms for screening-positive and screening-negative groups as the item with the highest proportion of respondents scoring 1 or higher, highest proportion scoring 3, and highest average score, respectively.

RESULTS

In screened positive women the most frequent symptom was feeling sad or miserable, and the most serious and important symptoms were both sleeping problems. Among those screened negative, self-blame was the most frequent, serious and important item. For women who screened positive in the first trimester, only self-blame and feeling overwhelmed showed stability over time. Symptoms in women screened negative were relatively stable. Four in ten women who had self-harm thoughts were screened negative.

CONCLUSION

Women who screened positive in EPDS differed from those screened negative in the characteristics in depressive symptoms. Intervention strategies focusing on the most frequent, serious and important symptoms (such as sadness and insomnia) may be worthwhile. Health practitioners should be trained to respond to a positive response to thoughts of self-harm, regardless of whether the women are screened positive or negative.

Efficacy of bright light therapy in perinatal depression: A randomized, double-blind, placebo-controlled study

BACKGROUND

Uncertainties and difficulties associated with the current treatment modalities for perinatal depression (PND) may cause some mothers to avoid treatment. Raising awareness about the effectiveness and safety of bright light therapy (BLT) may help to alleviate the challenges of PND. The main goal of this study was to evaluate the efficacy and safety of BLT versus placebo in PND.

METHOD

A total of 30 women who were either pregnant or in first year postpartum and diagnosed with major depressive disorder were enrolled; 23 completed the study. Patients were randomly assigned to either the BLT (10,000 lux) or placebo (<500 lux) group. BLT and placebo light were applied for 45 min in the morning every day for a 3-week period. The Montgomery-Åsberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale (HAM-D), and Edinburgh Postnatal Depression Scale (EPDS) were administered weekly to evaluate response and remission rates and depression scores.

RESULTS

There was no significant difference between the two groups in terms of baseline depression scores. At the end of the study, the response rates assessed according to MADRS were 75% for BLT and 18.2% for placebo (p = .006), and remission rates were 41.7% vs. 0% (p = .016), respectively. There was no significant difference between the groups (p > .05) in terms of treatment-related side effects. The main limitation of this study is its small sample size, which limits the generalizability of the study's findings.

CONCLUSION

The results indicate that BLT is more effective than placebo and is reliable in terms of side effects in PND patients. In order to expand the use of BLT in PND, new studies with larger sample sizes are needed.

Light therapy for seasonal affective disorder in visual impairment and blindness - a pilot study

OBJECTIVE

Seasonal and non-seasonal depression are prevalent conditions in visual impairment (VI). We assessed the effects and side effects of light therapy in persons with severe VI/blindness who experienced recurrent depressive symptoms in winter corresponding to seasonal affective disorder (SAD) or subsyndromal SAD (sSAD).

RESULTS

We included 18 persons (11 with severe VI, 3 with light perception and 4 with no light perception) who met screening criteria for sSAD/SAD in a single-arm, assessor-blinded trial of 6 weeks light therapy. In the 12 persons who completed the 6 weeks of treatment, the post-treatment depression score was reduced (p < 0.001), and subjective wellbeing (p = 0.01) and sleep quality were improved (p = 0.03). In 6/12 participants (50%), the post-treatment depression score was below the cut-off set for remission. In four participants with VI, side effects (glare or transiently altered visual function) led to dropout or exclusion.

CONCLUSION

Light therapy was associated with a reduction in depressive symptoms in persons with severe VI/blindness. Eye safety remains a concern in persons with residual sight.

Evaluation of salivary melatonin concentrations as a circadian phase maker of morning awakening and their association with depressive mood in postpartum mothers

The disruption of circadian rhythm is closely related to mood disorders in night-shift workers, and a similar situation may occur in postpartum mothers. However, the situations of postpartum mothers remain largely unknown because of a lack of an appropriate circadian phase marker in the clinical setting. This study aimed to evaluate whether salivary melatonin concentration at awakening can identify misalignment between awakening time and the biological clock system, which might be associated with depressive mood in some mothers. Ninety-eight healthy mothers who were currently the primary parental caregivers were recruited at 1 month after delivery. All mothers completed the Edinburgh Postnatal Depression Scale (EPDS) and wore an actigraphy watch at home for 3 consecutive days to determine nocturnal sleep variables. While wearing the actigraphy watch, they also collected saliva samples during the awakening period for a melatonin concentration assay. The results indicated that daily salivary melatonin levels after 30 min of awakening (hereafter, melatonin levels) were positively correlated with sleep onset time and negatively correlated with sleep offset time and total sleep time. Six mothers with an EPDS score of ≥9 (the cutoff value for Japanese women at high risk for postnatal depression) had an average melatonin level of either <4 pg/ml or >16 pg/ml for 3 d. Mothers with melatonin levels <4 pg/ml or >16 pg/ml tended to have elevated EPDS scores (4.93 ± 2.95 or 4.20 ± 2.93, mean ± standard deviation) compared with mothers with melatonin levels between 4 and 16 pg/ml (3.00 ± 2.12, p = .053). Mothers whose melatonin levels were >16 pg/ml had relatively later sleep onset time and shorter nocturnal sleep duration. Backward stepwise regression demonstrated that such high/low levels of melatonin were a significant predictor of EPDS scores. These results suggest that elevated melatonin levels after 30 min of awakening could identify a phase-delayed circadian rhythm in postpartum mothers, and that relatively higher or lower melatonin levels could be associated with increased depressive mood.

Chronobiology and Chronotherapy in Depression: Current Knowledge and Chronotherapeutic Promises

Background:

Depression is a heavily prevalent mental disorder. Symptoms of depression extend beyond mood, cognition, and behavior to include a spectrum of somatic manifestations in all organic systems. Changes in sleep and neuroendocrine rhythms are especially prominent, and disruptions of circadian rhythms have been closely related to the neurobiology of depression. With the advent of increased research in chronobiology, various pathophysiologic mechanisms have been proposed, including anomalies of sleep architecture, the effects of clock gene polymorphisms in monoamine metabolism, and the deleterious impact of social zeitgebers. The identification of these chronodisruptions has propelled the emergence of several chronotherapeutic strategies, both pharmacological and non-pharmacological, with varying degrees of clinical evidence.

Methods:

The fundamental objective of this review is to integrate current knowledge about the role of chronobiology and depression and to summarize the interventions developed to resynchronize biorhythms both within an individual and with geophysical time.

Results:

We have found that among the non-pharmacological alternatives, triple chronotherapywhich encompasses bright light therapy, sleep deprivation therapy, and consecutive sleep phase advance therapy-has garnered the most considerable scientific interest. On the other hand, agomelatine appears to be the most promising pharmacological option, given its unique melatonergic pharmacodynamics.

Conclusions:

Research in chronotherapy as a treatment for depression is currently booming. Novel interventions could play a significant role in adopting new options for the treatment of depression, with Tripe Cronotherapy standing out as the most promising treatment.

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.

Emerging issues and questions on peripartum depression prevention, diagnosis and treatment: a consensus report from the cost action riseup-PPD

BACKGROUND

Peripartum depression [PPD] is a public health problem which has been widely studied. Nonetheless, study findings and clinical guidelines for PPD treatment differ among countries and the condition is still underdiagnosed and undertreated, suggesting the importance of a global understanding of PPD. The Riseup-PPD Cost Action aims to establish a Pan-European and multidisciplinary network of researchers dedicated to the global understanding of PPD.

METHODS

A literature search was performed in different databases (e.g., Medline, PsychInfo) including a combination of terms related with PPD diagnosis, prevention, treatment and cost-effectiveness of its management. A narrative synthesis of the literature, together with a critical overview of the current issues/questions to be addressed within the topic of PPD were performed.

RESULTS

Emerging issues include challenges regarding definition and timing of PPD; heterogeneity in severity, timing of onset and assessment tools; comparative effectiveness of preventive and treatment interventions; help seeking for PPD; improving health professional's awareness of PPD; and cost-effectiveness of PPD management.

LIMITATIONS

The main limitation is the non-systematic nature of the literature search.

CONCLUSIONS

The Riseup-PPD network will deal with these challenges through four lines of action: (1)provide an updated and comprehensive synthesis of existing knowledge that can contribute to inform clinical recommendations and guidelines for PPD management; (2) clarify inconsistent findings concerning diagnosis, prevention and treatment of PPD; (3) develop new lines of research in the field of PPD; and (4) develop international recommendations for PPD diagnosis, prevention and treatment, ultimately influencing maternal mental health policymaking at global and local levels.

Use of bright light therapy for older adults with dementia

Bright light therapy is an accepted and commonly used treatment for seasonal affective and circadian rhythm disorders. In the past 20 years, researchers have examined the effectiveness of bright light therapy in improving depression and agitation in older adults with dementia. This article provides clinicians with a summary of the neurophysiology of bright light therapy, bright light research considerations, an evidence-based bright light protocol, problems related to bright light therapy, and clinical implications for bright light therapy in older adults with dementia. Bright light exposure is a safe, non-pharmacological treatment that is currently underutilised in this population. Clinicians may find bright light therapy beneficial as a primary or adjunctive treatment in reducing depression and agitation in older adults with dementia.

[Sleep disorders as one of the indicators of postpartum depression]

Postpartum depression in ICD-10 refers to mild mental and behavioral disorders associated with physiological disorders of the postpartum period F53.0. Diagnosis is based on criteria, one of which is sleep disorders. The objective of the review is to characterize the postpartum sleep disorders and to reflect their predictor value in the development of postpartum depression. Presomnic, intrasomnic and postsomnic disorders with negative consequences for both the mother and her child were found in sleep disorders of women with postpartum depression. Depression with sleep disorders significantly affect the quality of life of the mother and infant. Sleep disorders are one of the predictors of postpartum depression. Improving of sleep quality is an effective way to prevent the effects of postpartum depression.

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.

Ambient temperature and solar insolation are associated with decreased prevalence of SSRI-treated psychiatric disorders

Serotonergic function is known to fluctuate in association with light and temperature. Serotonin-related behaviors and disorders similarly vary with climatic exposure, but the associations are complex. This complexity may reflect the importance of dose and timing of exposure, as well as acclimation. This cross-sectional study tests how average climate exposures (ambient temperature and solar insolation) vary with the prevalence of a group of SSRI-treated disorders. For comparison, we similarly studied a group of disorders not treated by SSRIs (i.e substance use disorders). Psychiatric prevalence data were obtained from the Collaborative Psychiatric Epidemiology Surveys (CPES). Average yearly solar insolation was obtained from NASA's NLDAS-2 Forcing Dataset Information. Average yearly temperature was obtained from NOAA's US Climate Normals. Logistic regression models were generated to assess the relationship between these two climatic factors and the prevalence of SSRI-treated and substance use disorders. Age, gender, race, income, and education were included in the models to control for possible confounding. Temperature and insolation were significantly associated with the SSRI-responsive group. For an average 1 GJ/m²/year increase, OR was 0.90 (95% CI 0.85-0.96, p = 0.001), and for an average 10 °F increase, OR was 0.93 (95% CI 0.88-0.97, p = 0.001). This relationship was not seen with substance use disorders (insolation OR: 0.97, p = 0.682; temperature OR: 0.96, p = 0.481). These results warrant further investigation, but they support the hypothesis that chronic exposure to increased temperature and light positively impact serotonin function, and are associated with reduced prevalence of some psychiatric disorders. They also support further investigation of light and hyperthermia treatments.

A review of the studies on nonvisual lighting effects in the field of physiological anthropology

Here, we review the history and the trends in the research on the nonvisual effect of light in the field of physiological anthropology. Research on the nonvisual effect of light in the field of physiological anthropology was pioneered by Sato and colleagues in the early 1990s. These authors found that the color temperature of light affected physiological functions in humans. The groundbreaking event with regard to the study of nonvisual effects of light was the discovery of the intrinsically photosensitive retinal ganglion cells in the mammalian retina in the early 2000s. The interest of the physiological anthropology scientific community in the nonvisual effects of light has been increasing since then. A total of 61 papers on nonvisual effects of light were published in the Journal of Physiological Anthropology (including its predecessor journals) until October 2018, 14 papers (1.4/year) in the decade from 1992 to 2001, 45 papers (2.8/year) in the 16 years between 2002 and 2017, and two papers in 2018 (January-October). The number of papers on this topic has been increasing in recent years. We categorized all papers according to light conditions, such as color temperature of light, light intensity, and monochromatic light. Among the 61 papers, 11 papers were related to color temperature, 20 papers were related to light intensity, 18 papers were related to monochromatic light, and 12 papers were classified as others. We provide an overview of these papers and mention future research prospects.

Shortening day length: a potential risk factor for perinatal depression

The aim of this secondary analysis was to determine whether seasonal light exposure, categorized by type of day length, is associated with or predictive of depressive symptoms in late pregnancy and the first 3 months postpartum. Women (n = 279) expecting their first child were recruited from prenatal clinics and childbirth education classes. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale. Day lengths were categorized into short, lengthening, long and shortening. Data analysis included linear mixed models and multiple linear regression. When days were shortening (August to first 4 days of November) in late third trimester, depressive symptom scores were highest (35%) and continued to be higher at each postpartum assessment compared to other day length categories. Implications for clinical practice include increased vigilance for depressive symptoms, particularly if late pregnancy and birth occurs during the 3 months around the Autumn equinox when day length is shortening. Strategies that increase light exposure in late pregnancy and postpartum should also be considered.

Depressive disorders: Processes leading to neurogeneration and potential novel treatments

Mood disorders are wide spread with estimates that one in seven of the population are affected at some time in their life (Kessler et al., 2012). Many of those affected with severe depressive disorders have cognitive deficits which may progress to frank neurodegeneration. There are several peripheral markers shown by patients who have cognitive deficits that could represent causative factors and could potentially serve as guides to the prevention or even treatment of neurodegeneration. Circadian rhythm misalignment, immune dysfunction and oxidative stress are key pathologic processes implicated in neurodegeneration and cognitive dysfunction in depressive disorders. Novel treatments targeting these pathways may therefore potentially improve patient outcomes whereby the primary mechanism of action is outside of the monoaminergic system. Moreover, targeting immune dysfunction, oxidative stress and circadian rhythm misalignment (rather than primarily the monoaminergic system) may hold promise for truly disease modifying treatments that may prevent neurodegeneration rather than simply alleviating symptoms with no curative intent. Further research is required to more comprehensively understand the contributions of these pathways to the pathophysiology of depressive disorders to allow for disease modifying treatments to be discovered.

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.

Chronobiology, sleep-related risk factors and light therapy in perinatal depression: the "Life-ON" project

BACKGROUND

Perinatal depression (PND) has an overall estimated prevalence of roughly 12 %. Untreated PND has significant negative consequences not only on the health of the mothers, but also on the physical, emotional and cognitive development of their children. No certain risk factors are known to predict PND and no completely safe drug treatments are available during pregnancy and breastfeeding. Sleep and depression are strongly related to each other because of a solid reciprocal causal relationship. Bright light therapy (BLT) is a well-tested and safe treatment, effective in both depression and circadian/sleep disorders.

METHODS

In a 3-year longitudinal, observational, multicentre study, about 500 women will be recruited and followed-up from early pregnancy (10-15 gestational week) until 12 months after delivery. The primary aim of the present study is to systematically explore and characterize risk factors for PND by prospective sleep assessment (using wrist actigraphy, polysomnography and various sleep questionnaires) and bloodbased analysis of potential markers during the perinatal period (Life-ON study). Secondary aims are to explore the relationship between specific genetic polymorphisms and PND (substudy Life-ON1), to investigate the effectiveness of BLT in treating PND (substudy Life-ON2) and to test whether a short term trial of BLT during pregnancy can prevent PND (substudy Life-ON3).

DISCUSSION

The characterization of specific predictive and risk factors for PND may substantially contribute to improve preventive medical and social strategies for the affected women. The study results are expected to promote a better understanding of the relationship between sleep disorders and the development of PND and to confirm, in a large sample of women, the safety and efficacy of BLT both in prevention and treatment of PND.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02664467 . Registered 13 January 2016.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly

BACKGROUND

The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals.

METHODS

Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on "Special Populations" is the sixth of six guidelines articles.

RESULTS

Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported.

CONCLUSIONS

Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD.

[Treatment of psychiatric disorders during pregnancy and the breast feeding : Psychotherapy and other nondrug therapies]

The majority of women suffering from psychiatric disorders in pregnancy and the breast feeding prefer psychotherapy and other nonpharmacological treatment over psychopharmacological treatment although the risk of malformations and postnatal complications in children exposed to psychopharmacological drugs must be regarded as acceptable in moderate to severely ill patients. Data are lacking, but several psychotherapeutic and biological treatments as well as noninvasive brain stimulation procedures have been investigated to treat depressive episodes and anxiety disorders in pregnancy and the breast feeding. In mild to moderate depressive episodes different psychotherapy treatments and counseling are significantly more effective in reducing depressive symptoms than no treatment.The same seems to be true for anxiety disorders; however, studies on this are sparse. Treatment by telephone and internet also seems to improve symptoms, which is of interest especially in the less flexible group of breast feeding women and for the development of future health care structures. Noninvasive stimulation treatment has been shown to be an effective nonpharmacological therapeutic option. Data for other recent noninvasive brain stimulation treatments and biological treatments as well as exercise therapy are sparse. In severe and delusional cases as well as treatment-resistant depressive episodes, electroconvulsive therapy should be considered in pregnant women. Because several patients prefer nonpharmacological therapy during this period, those should be applied if available and feasible. Regarding nonpharmacological treatment of obsessive-compulsive disorder, bipolar disorder and schizophrenia during pregnancy and the breast feeding, no recommendation can currently be given.

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

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

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

RESULTS

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

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address 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

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

An Evidence Review and Model for Prevention and Treatment of Postpartum Posttraumatic Stress Disorder

Postpartum posttraumatic stress disorder (P-PTSD) is a variant of posttraumatic stress disorder (PTSD) that, although relatively prevalent, is under-researched. Up to one-third of women in the United States describe childbirth as traumatic, with 9 percent of women meeting the criteria for PTSD outlined by the American Psychiatric Association. These statistics are sobering in light of common use of analgesia during birth as well as hospital birth environments promoting family-centered maternity care. How can a seemingly natural event, such as childbirth, be associated with PTSD? This review includes a description of key variables associated with P-PTSD. Socioeconomic, environmental and genetic determinants are discussed, as are evidence-based prevention and treatment approaches.

The psychiatry of light

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

Nonpharmacologic treatments for depression related to reproductive events

There is a growing body of evidence suggesting that nonpharmacological interventions have an appropriate place in the treatment of major depressive disorders (MDDs) as both stand-alone and supplemental treatments. Because women may be reluctant to use psychotropic medications due to strong values or treatment preferences during specific reproductive events, clinicians need to be able to offer empirically based alternatives to medication. In this review, we present recent findings from studies of acupuncture, bright light therapy, electroconvulsive therapy, omega fatty acid supplementation, physical activity, and psychosocial intervention for women experiencing depressive symptoms in the contexts of menstruation, pregnancy, postpartum, and menopause.

Perinatal depression: an update and overview

Over the last 3 years there have been notable developments in the screening and treatment of perinatal depression. Most importantly, the DSM-V has made only minor changes in the diagnostic criteria for perinatal depression as compared to the DSM-IV; "perinatal," as opposed to "postpartum," is a specifier for depression with a requirement that the depression onset occurs during pregnancy or the first 4 weeks postpartum. Advances in the treatment of perinatal depression have been made over the last 3 years, including both prevention and acute interventions. Additional support has emerged confirming the primary risk factors for perinatal depression: a personal or family history, low SES and poor interpersonal support. There is general agreement that universal screening be conducted for all perinatal women, by both the woman's obstetrician and the baby's pediatrician.

On 'polypharmacy' and multi-target agents, complementary strategies for improving the treatment of depression: a comparative appraisal

Major depression is a heterogeneous disorder, both in terms of symptoms, ranging from anhedonia to cognitive impairment, and in terms of pathogenesis, with many interacting genetic, epigenetic, developmental and environmental causes. Accordingly, it seems unlikely that depressive states could be fully controlled by a drug possessing one discrete mechanism of action and, in the wake of disappointing results with several classes of highly selective agent, multi-modal treatment concepts are attracting attention. As concerns pharmacotherapy, there are essentially two core strategies. First, multi-target antidepressants that act via two or more complementary mechanisms and, second, polypharmacy, which refers to co-administration of two distinct drugs, usually in separate pills. Both multi-target agents and polypharmacy ideally couple a therapeutically unexploited action to a clinically established mechanism in order to enhance efficacy, moderate side-effects, accelerate onset of action and treat a broader range of symptoms. The melatonin MT1/MT2 agonist and 5-HT(2C) antagonist, agomelatine, which is effective in the short- and long-term treatment of depression, exemplifies the former approach, while evidence-based polypharmacy is illustrated by the adjunctive use of second-generation antipsychotics with serotonin reuptake inhibitors for treatment of resistant depression. Histone acetylation and methylation, ghrelin signalling, inflammatory modulators, metabotropic glutamate-7 receptors and trace amine-associated-1 receptors comprise attractive substrates for new multi-target and polypharmaceutical strategies. The present article outlines the rationale underpinning multi-modal approaches for treating depression, and critically compares and contrasts the pros and cons of established and potentially novel multi-target vs. polypharmaceutical treatments. On balance, the former appear the most promising for the elaboration, development and clinical implementation of innovative concepts for the more effective management of depression.

Association between melanopsin gene polymorphism (I394T) and pupillary light reflex is dependent on light wavelength

Background

Our aim was to determine the association between melanopsin gene polymorphism and pupillary light reflex under diverse photic conditions, including different intensities and wavelengths.

Methods

A total of 195 visually corrected subjects volunteered for investigation of the melanopsin gene of single nucleotide polymorphism (SNP) of rs1079610 (I394T). The genotype groups were TT (n = 126), TC (n = 55), and CC (n = 8), and 75 of the subjects, including subjects with TT (n = 34), TC (n = 33), and CC (n = 8) participated in our experiment. Three monochromatic lights with peak wavelengths of 465 nm (blue), 536 nm (green), and 632 nm (red) were prepared, and each light was projected to the subjects with five intensities, 12, 13, 14, 14.5 and 15 log photons/(cm² s), for one minute. The pupil size of the left eye was measured under each light condition after a 1-minute adaptation.

Results

The pupils of the TC + CC genotypes (n = 38) were significantly smaller than those of the TT genotype (n = 31) under a blue (463 nm) light condition with 15 log photons/(cm² s) (P < 0.05). In contrast, there were no significant differences under green (536 nm) and red (632 nm) light conditions. Conversely, relative pupil constrictions of the TC + CC genotypes were greater than those of the TT genotype under both blue and green conditions with high intensities (14.5 and 15 log photons/(cm² s)). In contrast, there were no significant differences between genotype groups in pupil size and relative pupilloconstriction under the red light conditions.

Conclusions

Our findings suggest that the melanopsin gene polymorphism (I394T) functionally interacts with pupillary light reflex, depending on light intensity and, particularly, wavelength, and that under a light condition fulfilling both high intensity and short wavelength, the pupillary light response of subjects with the C allele (TC + CC) is more sensitive to light than that of subjects with the TT genotype.

Antepartum depression severity is increased during seasonally longer nights: relationship to melatonin and cortisol timing and quantity

Current research suggests that mood varies from season to season in some individuals, in conjunction with light-modulated alterations in chronobiologic indices such as melatonin and cortisol. The primary aim of this study was to evaluate the effects of seasonal variations in darkness on mood in depressed antepartum women, and to determine the relationship of seasonal mood variations to contemporaneous blood melatonin and cortisol measures; a secondary aim was to evaluate the influence of seasonal factors on measures of melancholic versus atypical depressive symptoms. We obtained measures of mood and overnight concentrations of plasma melatonin and serum cortisol in 19 depressed patients (DP) and 12 healthy control (HC) antepartum women, during on-going seasonal variations in daylight/darkness, in a cross-sectional design. Analyses of variance showed that in DP, but not HC, Hamilton Depression Rating Scale (HRSD) scores were significantly higher in women tested during seasonally longer versus shorter nights. This exacerbation of depressive symptoms occurred when the dim light melatonin onset, the melatonin synthesis offset, and the time of maximum cortisol secretion (acrophase) were phase-advanced (temporally shifted earlier), and melatonin quantity was reduced, in DP but not HC. Serum cortisol increased across gestational weeks in both the HC and DP groups, which did not differ significantly in cortisol concentration. Nevertheless, serum cortisol concentration correlated positively with HRSD score in DP but not HC; notably, HC showed neither significant mood changes nor altered melatonin and cortisol timing or quantity in association with seasonal variations. These findings suggest that depression severity during pregnancy may become elevated in association with seasonally related phase advances in melatonin and cortisol timing and reduced melatonin quantity that occur in DP, but not HC. Thus, women who experience antepartum depression may be more susceptible than their nondepressed counterparts to phase alterations in melatonin and cortisol timing during seasonally longer nights. Interventions that phase delay melatonin and/or cortisol timing-for example, increased exposure to bright evening light-might serve as an effective intervention for antepartum depressions whose severity is increased during seasonally longer nights.

Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression

BACKGROUND

A meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, diverse non-pharmacological treatment options are needed.

OBJECTIVES

To assess the effect of interventions other than pharmacological, psychosocial, or psychological interventions compared with usual antepartum care in the treatment of antenatal depression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013), scanned secondary references and contacted experts in the field to identify other published or unpublished trials.

SELECTION CRITERIA

All published and unpublished randomised controlled trials of acceptable quality evaluating non-pharmacological/psychosocial/psychological interventions to treat antenatal depression.

DATA COLLECTION AND ANALYSIS

Both review authors participated in the evaluation of methodological quality and data extraction. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Six trials were included involving 402 women from the United States, Switzerland, and Taiwan. For most comparisons a single trial contributed data and there were few statistically significant differences between control and intervention groups.In a trial with 38 women maternal massage compared with non-specific acupuncture (control group) did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.25 to 2.53; mean difference (MD) -2.30, 95% CI -6.51 to 1.91 respectively). In another trial with 88 women there was no difference in treatment response or depression remission rates in women receiving maternal massage compared with those receiving non-specific acupuncture (RR 1.33, 95% CI 0.82 to 2.18; RR 1.14, 95% CI 0.59 to 2.19 respectively).In a trial with 35 women acupuncture specifically treating symptoms of depression, compared with non-specific acupuncture, did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (RR 0.47, 95% CI 0.11 to 2.13; MD -3.00, 95% CI -8.10 to 2.10). However, women who received depression-specific acupuncture were more likely to respond to treatment compared with those receiving non-specific acupuncture (RR 1.68, 95% CI 1.06 to 2.66).In a trial with 149 women, maternal massage by a woman's significant other, compared with standard care, significantly decreased the number of women with depressive symptomatology immediately post-treatment (MD -6.70, 95% CI -9.77 to -3.63). Further, women receiving bright light therapy had a significantly greater change in their mean depression scores over the five weeks of treatment than those receiving a dim light placebo (one trial, n = 27; MD -4.80, 95% CI -8.39 to -1.21). However, they were not more likely to have a treatment response or experience a higher remission rate (RR 1.79, 95% CI 0.90 to 3.56; RR 1.89, 95% CI 0.81 to 4.42).Lastly, two trials examined the treatment effect of omega-3 oils. Women receiving omega-3 had a significantly lower mean depression score following eight weeks of treatment than those receiving a placebo (one trial, n = 33; MD -4.70, 95% CI -7.82 to -1.58). Conversely, in a smaller trial (21 women) there was no significant difference in the change in mean depression scores for women receiving omega-3 and those receiving a placebo (MD 0.36, 95% CI -0.17 to 0.89), and women who received omega-3 were no more likely to respond to treatment (RR 2.26, 95% CI 0.78 to 6.49) or have higher remission rates (RR 2.12, 95% CI 0.51 to 8.84). Women in the placebo group were just as likely to report a side effect as those in the omega-3 group (RR 1.12, 95% CI 0.56 to 2.27).

AUTHORS' CONCLUSIONS

The evidence is inconclusive to allow us to make any recommendations for depression-specific acupuncture, maternal massage, bright light therapy, and omega-3 fatty acids for the treatment of antenatal depression. The included trials were too small with non-generalisable samples, to make any recommendations.