BRIGHT LIGHT AUGMENTS ANTIDEPRESSANT EFFECTS
Richard T. Loving, R.N., D.N.Sc.,* Daniel F. Kripke, M.D., and Stephen R. Shuchter, M.D.
Inpatient studies have suggested that bright light therapy can be used to sustainthe antidepressant effects of wake therapy (sleep deprivation). In an outpatienttrial, a half night of home wake treatment was followed by 1 week of lighttreatment. All subjects had Major Depressive Disorders according to DSM-IVcriteria and were receiving concomitant antidepressant medication. Subjectswere randomly assigned to receive either 10,000 lux bright white light for30 min between 6 and 9 AM or dim red (placebo) light at a comparable time.
Seven subjects completed treatment with bright white light and six completedtreatment with placebo. On the Hamilton Depression Rating Scale (HDRS17,SIGH-SAD-SR version), the group receiving bright light improved 27% in 1week (P=0.002). The group receiving placebo did not improve, except for oneoutlier. The benefit of bright light was significant compared to placebo withremoval of the outlier (P< 0.025).
Depression and Anxiety 16:1–3, 2002.
All were diagnosed as having Major Depressive
Disorder according to DSM-IV criteria, and none
ne half night of wake therapy can produce an
had seasonal trait. Subjects were studied throughout
immediate antidepressant benefit, especially when the
the year. All were receiving standard antidepressant
patient remains awake in the second half of the night
medications and supportive psychotherapy, some for
[Wu and Bunney, 1990; Wirz-Justice and van den
many months, but had not yet experienced a satisfac-
Hoofdakker, 1999]. (The term ‘‘wake therapy’’ has been
tory response. Each patient had a primary psychiatrist
suggested to avoid the negative cognitive connotations
outside the research team. Medications and psy-
of the term ‘‘sleep deprivation’’ when waking is
chotherapy were maintained during the research
arranged for treatment.) Unfortunately, patients com-
protocol. The protocol did not alter standard therapy
monly relapse after a full night’s sleep, so many
in any way, and light was used only to augment existing
investigations have searched for medications or other
treatment. The primary psychiatrist was free to
methods of maintaining the rapid benefit that patients
intervene at any time during the study as prior to the
may receive. In an inpatient study, Neumeister et al.
study. Data on medications is presented in Table 1.
 found that excellent responses to wake therapy
Data on changes in psychotherapeutic intervention
can be maintained if the patient receives bright light
were not available. However, there was no indication
treatments every morning thereafter. A 35% improve-
that any significant change in therapeutic approach
ment in depression as compared to dim light control
treatment was observed at the end of a week. Thisbenefit has recently been replicated by Bloching et al.
 and Fritzsche et al. . We examined
University of California, San Diego, La Jolla, California
whether this antidepressant benefit could be obtained
Contract grant sponsor: National Institute On Aging; Grant
*Correspondence to: Dr. Richard T. Loving, Department of
Psychiatry 0667, University of California, San Diego, La Jolla,California 92093-0667. E-mail: [email protected]
Thirteen patients of the University of California, San
Received for publication 12 April 2001; Accepted 31 January 2002
Diego (UCSD) outpatient clinic, eleven women andtwo men, gave written informed consent for this study,
under supervision of UCSD’s institutional review
board. There mean age was 44 years (range 26–56).
TABLE 1. Individual medications regimens at time of study
Recent trial of Serzone not tolerated, stopped at 50 mg.
Bupropion 300 mgTrazodone 300 mgDiazepam 10 mgValproate 250 mg
At the start of the study, a baseline Hamilton
due entirely to one outlier, whose HDRS17 self-rating
Depression Rating Scale (HDRS17) was completed,
dropped from 32 to 5, even though her therapist felt
using the SIGH-SAD-SR [Williams et al., 1990],
that she did not improve. Because the change score for
which contains a self-rating form of the HDRS17.
this subject was an outlier 2.58 SD from the mean
Each patient then agreed to awaken at 3:00 am while at
change score, and it skewed the distribution, this
home and to remain awake for the remainder of thenight. To monitor compliance, patients were asked totelephone a telephone answering machine every half
TABLE 2. Hamilton depression rating scale (HDRS17)
hour until beginning light treatment. That morning
patients commenced experimental light treatmentwhich continued for six additional mornings. The light
treatment was scheduled for 30 min between 6 and9
am, and consisted of exposure to a light box at eye
level from a distance of 18 inches. Patients were
randomly assigned to receive either 10,000 lux bright
white light from an Apollo Lighting Systems Brite
Lite III or 100 lux dim red placebo light from a
comparable box with a dark red filter. At the end of the
1-week treatment, the depression self-ratings were
Initial HDRS17 scores ranged from 10 to 41, with a
mean of 21.6, and were not significantly different
between those assigned to bright or placebo light(Table 2). The bright-light-treated group improved
This research was performed on human subjects and complied with the
27% on HDRS17 at the end of the week (P ¼
Code of Ethics of the World Medical Association (Declaration of Helsinki)
The placebo group improved 20%, but the gain was
and the standards established by the UCSD Institutional Review Board
not significant. The placebo group improvement was
and the National Institutes of Health.
Research Article: Bright Lights and Antidepressant Effects
subject was excluded in computing HDRS17 change
until more comparative studies are done, we cannot be
scores from baseline to the end of the 1-week
certain of this conclusion. Possibly, bright light alone
treatment. Excluding this outlier, the placebo group
may produce an excellent antidepressant response in
did not improve, and the benefit of bright light was
1–4 weeks, but the best responses seem to occur in
significant compared to placebo (t=2.82, P<0:025; two-
combination with medication and wake therapy
tailed). The group difference was not significant if the
outlier was retained. Mann-Whitney (nonparametric)
An important limitation of this study was the small
tests of the change scores were conducted. Including
number of subjects, since the study had to be
the outlier resulted in P=0:151; and when the outlier
terminated before planned subject accrual, due to
was excluded, P=0:028: The effect size, eta squared,
administrative problems. A second limitation was that
was Z2=0:896 and Z2=0:892; respectively.
the contrast between bright light and placebo wouldnot appear statistically significant without removal of
an outlier. A third limitation is the lack of follow-upbeyond 1 week. Currently, we are attempting a new
Patients with major depressive disorders who were
trial with 4 weeks of bright light treatment.
treated with the combination of bright light, wake
Acknowledgements. Apollo Lighting Systems sup-
therapy, and continuing medication improved 27%
plied lighting fixtures for this research.
within 1 week. The response was especially gratifyingsince a number of the patients had not been remittingwith antidepressant medication and psychotherapy, andthe placebo group did not improve within the 1-week
time span. Medication changes did not appear to
Bloching B, Dechene C, Taschner KL. 2000. Outlasting antidepres-
contribute to this difference. The treatment group had
sant effect of late partial sleep deprivation by bright light therapy.
six out of seven subjects with stable medication
regimen for 2 months or more and the placebo group
Fritzsche M, Heller R, Hill H, Kick H. 2001. Sleep deprivation as a
had five out of six subjects with stable medication
predictor of response to light therapy in major depression. J Affect
regimen for 2 months or more and one subject on no
medication (Table 1). The benefits achieved by out-
Khan A, Warner HA, Brown WA. 2000. Symptom reduction and
suicide risk in patients treated with placebo in antidepressant
patients in the home were comparable to those
clinical trials. Arch Gen Psychiatry 57:311–328.
achieved by inpatients in the study by Neumeister
Kripke DF. 1998. Light treatment for nonseasonal depression:
et al.  and replications. [Bloching et al., 2000;
speed, efficacy, and combined treatment. J Affect Dis 49:109–117.
Neumeister A, Goessler R, Lucht M, Kapitany T, Bamas C, Kasper S.
The magnitude of benefit by which bright light,
1996. Bright light therapy stabilizes the antidepressant effect of
wake therapy, and medication exceeded the benefits of
partial sleep deprivation. Biol Psychiatry 39:16–21.
placebo, wake therapy, and medication was 27% within
Williams JBW, Link MJ, Rosenthal NE, Terman M. 1990. Seasonal
1 week. This is a superior response, compared to the
affective disorder assessment tools packet. In: Terman M, editor.
benefits of antidepressant drugs, which produce
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relative benefits of only 8–11% contrasted to placebo
Wirz-Justice A, van den Hoofdakker RH. 1999. Sleep deprivation in
after 8 weeks [Khan et al., 2000]. It appears that bright
depression: what do we know, where do we go? Biol Psychiatry
light combined with wake therapy and medication
might produce a much better antidepressant response
Wu JC, Bunney WE. 1990. The biological basis of an antidepressant
much more rapidly than our available antidepressant
response to sleep deprivation and relapse: review and hypothesis.
drugs. However, despite powerful effects shown here,
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