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.
[1996] 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.
[2000] and Fritzsche et al. [2001]. 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 0:002).
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. [1996] 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 SLTBR 1988–1990: The Complete Works. New York: SLTBR.
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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