|
Light therapy in bulimia
nervosa: a double-blind, placebo-controlled
study.
Blouin AG; Blouin JH; Iversen H; Carter J; Goldstein C;
Goldfield G; Perez E Department of Psychiatry, Ottawa Civic
Hospital, ON, Canada.
Psychiatry Res (Ireland) Feb 28 1996, 60 (1) p1-9
The effects of light therapy on food intake and
affective symptoms of bulimia nervosa (BN) were examined in
a double-blind study. Eighteen women who met DSM-III-R
criteria for BN were randomly assigned to receive either
2500 lux of bright light (experimental condition) or
< 500 lux of dim light (placebo condition) daily in
the early evening for a 1-week period. The Structured
Interview Guide for the Hamilton Depression Rating
Scale-Seasonal Affee Bulimic Symptoms Checklist were
administered to subjects before light exposure, after 1
week of light exposure, and after 7 days of withdrawal of
light exposure. Throughout the study, the Profile of Mood
States and the Daily Binge Record were completed daily.
Compared with subjects in the dim light condition, subjects
in the bright light condition showed a significant
improvement in depressed mood during light exposure, as
measured by both the BDI and the SIGH-SAD. There was a
return to pretreatment levels of depression after
withdrawal of light exposure. No changes in depression were
noted in the placebo group. No effect of light therapy was
found on the frequency, size, or content of binge-eating
episodes. The results are discussed in terms of the
physiological processes associated with light therapy and
seasonal affective disorder that may underlie the affective
and food intake symptoms of BN.
Bright light treatment of
winter depression: a placebo-controlled trial
Eastman CI; Young MA; Fogg LF; Liu L; Meaden PM
Department of Psychology, Rush-Presbyterian-St Luke's
Medical Center, Chicago, Ill 60612, USA
ceastman@rush.edu
Arch Gen Psychiatry (United States) Oct 1998 , 55 (10)
p883-9,
BACKGROUND: Bright light therapy is the recommended
treatment for winter seasonal affective disorder (SAD).
However, the studies with the best placebo controls have
not been able to demonstrate that light treatment has a
benefit beyond its placebo effect.
METHODS: Ninety-six patients with SAD completed the
study. Patients were randomly assigned to 1 of 3 treatments
for 4 weeks, each 1.5 hours per day: morning light (average
start time about 6 AM), evening light (average start about
9 PM), or morning placebo (average start about 6 AM). The
bright light (approximately 6000 lux) was produced by light
boxes, and the placebos were sham negative-ion generators.
Depression ratings using the Structured Interview Guide for
the Hamilton Depression Rating Scale, SAD version
(SIGH-SAD) were performed weekly.
RESULTS: There were no differences among the 3 groups in
expectation ratings or mean depression scores after 4 weeks
of treatment. However, strict response criteria revealed
statistically significant differences; after 3 weeks of
treatment morning light produced more of the complete or
almost complete remissions than placebo. By 1 criterion
(24-item SIGH-SAD score <50% of baseline and
< or =8), 61% of the patients responded to morning
light, 50% to evening light, and 32% to placebo after 4
weeks of treatment.
CONCLUSIONS: Bright light therapy had a specific
antidepressant effect beyond its placebo effect, but it
took at least 3 weeks for a significant effect to develop.
The benefit of light over placebo was in producing more of
the full remissions.
Efficacy of light versus
tryptophan therapy in seasonal affective
disorder.
Ghadirian AM, Murphy BE, Gendron MJ Department of
Psychiatry, McGill University, Royal Victoria Hospital,
Montreal, Quebec, Canada.
J Affect Disord 1998 Jul;50(1):23-7
BACKGROUND: Although light therapy has become the
accepted treatment for patients suffering from seasonal
affective disorder (SAD, winter depression), almost 40% of
these patients do not respond, and require an alternative
treatment.
METHODS: The therapeutic effects of light versus
tryptophan on SAD were studied in a repeated measures
design in 13 SAD patients (11 women, 2 men). Light therapy
for 2 weeks or tryptophan for 4 weeks was given, separated
by a one week washout period. All were assessed with the
modified Hamilton Depression Rating scale (SIGH-SAD) at the
beginning and end of each treatment.
RESULTS: Four (31%) of the patients did not respond to
either therapy. Four tryptophan-resistant patients
responded to light therapy, while one light
therapy-resistant patient responded to tryptophan. Relapse
occurred rapidly after stopping light therapy but not after
stopping tryptophan therapy.
CONCLUSIONS: There were significant therapeutic effects
of both light (p = 0.012) and tryptophan (p = 0.014) on
SAD, which were not significantly different from each
other. There may be a time difference between the residual
pharmacokinetic effects after stopping therapy.
LIMITATIONS: The groups studied were small. This was an
open study.
CLINICAL RELEVANCE: Tryptophan was equally effective to
light therapy in treating SAD, but relapse after withdrawal
of tryptophan probably occurs more slowly.
L-tryptophan augmentation
of light therapy in patients with seasonal affective
disorder.
Lam RW; Levitan RD; Tam EM; Yatham LN; Lamoureux S; Zis
AP Department of Psychiatry, University of British
Columbia, Vancouver rlam@unixg.ubc.ca
Can J Psychiatry (Canada) Apr 1997, 42 (3) p303-6
OBJECTIVE: Up to one-third of patients with seasonal
affective disorder (SAD) do not have a full response to
light therapy. Given the evidence for serotonergic
dysregulation in SAD, we examined the possible role of
l-tryptophan as an augmentation strategy for nonresponders
and partial responders to light therapy.
METHOD: Eligible drug-free patients meeting DSM-IV
criteria for SAD were treated for 2 weeks using a standard
morning light therapy regimen (10,000 lux cool-white
fluorescent light for 30 minutes). Partial and
nonresponders were treated for 2 weeks with open-label
l-tryptophan (1 g 3 times daily) while light therapy was
continued. Ratings at baseline and follow-up included the
29-item Structured Interview Guide for the Hamilton
Depression Rating Scale, SAD version (SIGH-SAD) and the
Clinical Global Impression (CGI) scale.
RESULTS: Sixteen patients began the l-tryptophan
augmentation phase. Two patients discontinued medications
within 3 dg treatment, the addition of l-tryptophan
resulted in significant reduction of mean depression
scores. Nine of 14 patients (64%) showed very good clinical
responses to combined treatment and minimal side
effects.
CONCLUSION: This open-label study suggests that
l-tryptophan may be an effective augmentation strategy for
those patients with SAD who show limited or poor response
to bright ligh therapy. Further placebo-controlled studies
are warranted to demonstrate efficacy.
Vitamin D3 enhances mood
in healthy subjects during winter.
Lansdowne AT, Provost SC Department of Psychology, The
University of Newcastle, Callaghan NSW, Australia.
Psychopharmacology (Berl) 1998 Feb;135(4):319-23
Mood changes synchronised to the seasons exist on a
continuum between individuals, with anxiety and depression
increasing during the winter months. An extreme form of
seasonality is manifested as the clinical syndrome of
seasonal affective disorder (SAD) with carbohydrate
craving, hypersomnia, lethargy, and changes in circadian
rhythms also evident. It has been suggested that
seasonality and the symptoms of SAD may be due to changing
levels of vitamin D3, the hormone of sunlight, leading to
changes in brain serotonin. Forty-four healthy subjects
were given 400 IU, 800 IU, or no vitamin D3 for 5 days
during late winter in a random double-blind study. Results
on a self-report measure showed that vitamin D3
significantly enhanced positive affect and there was some
evidence of a reduction in negative affect. Results are
discussed in terms of their implications for seasonality,
SAD, serotonin, food preference, sleep, and circadian
rhythms.
Morning vs evening light
treatment of patients with winter depression.
Lewy AJ, Bauer VK, Cutler NL, Sack RL, Ahmed S, Thomas
KH, Blood ML, Jackson JM Department of Psychiatry, Oregon
Health Sciences University, Portland 97201-3098, USA.
Arch Gen Psychiatry 1998 Oct;55(10):890-6
BACKGROUND: According to the phase-shift hypothesis for
winter depression, morning light (which causes a circadian
phase advance) should be more antidepressant than evening
light (which causes a delay). Although no studies have
shown evening light to be more antidepressant than morning
light, investigations have shown either no difference or
morning light to be superior. The present study assesses
these light-exposure schedules in both crossover and
parallel-group comparisons.
METHODS: Fifty-one patients and 49 matched controls were
studied for 6 weeks. After a prebaseline assessment and a
light/dark and sleep/wake adaptation baseline week,
subjects were exposed to bright light at either 6 to 8 AM
or 7 to 9 PM for 2 weeks. After a week of withdrawal from
light treatment, they were crossed over to the other light
schedule. Dim-light melatonin onsets were obtained 7 times
during the study to assess circadian phase position.
RESULTS: Morning light phase-advanced the dim-light
melatonin onset and was more antidepressant than evening
light, which phase-delayed it. These findings were
statistically significant for both crossover and
parallel-group comparisons. Dim-light melatonin onsets were
generally delayed in the patients compared with the
controls.
CONCLUSIONS: These results should help establish the
importance of circadian (morning or evening) time of light
exposure in the treatment of winter depression. We
recommend that bright-light exposure be scheduled
immediately on awakening in the treatment of most patients
with seasonal affective disorder.
Effects of tryptophan
depletion on drug-free patients with seasonal affective
disorder during a stable response to bright light
therapy.
Neumeister A; Praschak-Rieder N; Besselmann B; Rao ML;
Gluck J; Kasper S Department of General Psychiatry, Vienna
University, Austria alexn@box-a.nih.gov
Arch Gen Psychiatry (United States) Feb 1997, 54 (2)
p133-8
BACKGROUND: A dysfunction of the serotonin system may
play a major role in the pathogenesis of seasonal affective
disorder. Bright light therapy has been shown to be
effective in the treatment of winter depression in patients
with seasonal affective disorder. Light therapy-induced
remission from depression may be associated with changes in
brain serotonin function.
METHODS: After at least 2 weeks of clinical remission,
12 drug-free patients who had had depression with seasonal
affective disorder underwent tryptophan depletion in a
double-blind, placebo-controlled, balanced cross-over
design study.
RESULTS: Short-term tryptophan depletion induced a
significant decrease in plasma free and total tryptophan
levels (P < .001 for both, repeated measures
analysis of variance), with peak effects occurring 5 hours
after ingestion of a tryptophan-free amino acid drink. It
emerged that tryptophan depletion leads to a transient
depressive relapse, which was most pronounced on the day
after the tryptophan-depletion testing. No clinically
relevant mood changes were observed in the control
testing.
CONCLUSIONS: The maintenance of light therapy-induced
remission from depression in patients with seasonal mood
cycles seems to depend on the functional integrity of the
brain serotonin system. Our results suggest that the
serotonin system might be involved in the mechanism of
action of light therapy.
Effects of tryptophan
depletion in fully remitted patients with seasonal
affective disorder during summer.
Neumeister A, Praschak-Rieder N, Hesselmann B, Vitouch
O, Rauh M, Barocka A, Kasper S Department of General
Psychiatry and Institute of Psychology, University of
Vienna, Austria.
Psychol Med 1998 Mar;28(2):257-64
BACKGROUND: Deficiencies in brain serotonin function are
believed to play an important role in the pathophysiology
of seasonal affective disorder/winter type (SAD). However,
no direct evidence has been reported so far that lowered
brain serotonin activity causes the symptoms of SAD.
METHODS: We studied 11 SAD patients who had suffered
recurrent winter depressive episodes of SAD and were fully
recovered and off treatment during the summer. In a
randomized, balanced, double-blind crossover design
patients received two amino acid beverages, one containing
tryptophan and the other containing no tryptophan but
otherwise identical. Behavioural ratings and plasma total
and free tryptophan concentrations were assessed at
baseline before administration of the amino acid beverages
and at several time points afterwards.
RESULTS: The tryptophan-free amino acid beverage induced
significant decreases of plasma total and free tryptophan
levels and both levels increased during sham depletion
(condition x time interaction: P < 0.001).
Tryptophan depletion, but not sham depletion caused a
transient return of depressive symptoms (condition x time
interaction: P < 0.001).
CONCLUSIONS: The present study demonstrates that SAD
patients in remission during the summer are vulnerable to a
return of depression when depleted of tryptophan. This
finding supports the importance of serotonergic mechanisms
in the pathophysiology of SAD.
Seasonal affective
disorder.
Partonen T, Lonnqvist J Department of Psychiatry,
University of Helsinki, National Public Health Institute,
Finland timo.partonen@ktl.fi
Lancet 1998 Oct 24;352(9137):1369-74
Seasonal affective disorder (SAD) is a form of recurrent
depressive or bipolar disorder, with episodes that vary in
severity. Seasonal patterns of depressive episodes are
common, but SAD seems to be less common than such patterns
suggest. SAD was at first believed to be related to
abnormal melatonin metabolism, but later findings did not
support this hypothesis. Studies of brain serotonin
function support the hypothesis of disturbed activity. The
short-allele polymorphism for serotonin transporter is more
common in patients with SAD than in healthy people.
Atypical depressive symptoms commonly precede impaired
functioning, and somatic symptoms are frequently the
presenting complaint at visits to family physicians. The
best treatment regimens include 2500 Ix of artificial light
exposure in the morning. When patients seem to have no
response or to prefer another treatment, antidepressants
should be considered.
A controlled trial of
light therapy for the treatment of pediatric seasonal
affective disorder.
Swedo SE; Allen AJ; Glod CA; Clark CH; Teicher MH;
Richter D; Hoffman C; Hamburger SD; Dow S; Brown C;
Rosenthal NE Department of Psychiatry, McLean Hospital,
Belmont, MA, USA.
J Am Acad Child Adolesc Psychiatry (United States) Jun
1997, 36 (6) p816-21
OBJECTIVE: To evaluate the efficacy of light therapy for
the treatment of pediatric seasonal affective disorder
(SAD).
METHOD: 28 children (aged 7 to 17 years) at two
geographically distinct sites were enrolled in a
double-blind, placebo-controlled, crossover trial of
bright-light treatment. Subjects initially entered a
week-long baseline period during which they wore dark
glasses for an hour a day. They were then randomly assigned
to receive either active treatment (1 hour of bright-light
therapy plus 2 hours of dawn simulation) or placebo (1 hour
of clear goggles plus 5 minutes of low-intensity dawn
simulation) for 1 week. The treatment phase was followed by
a second dark-glasses phase lasting 1 to 2 weeks. After
this phase, the children received the alternate treatment.
Response was measured using the parent and child versions
of the Structured Interview Guide for the Hamilton
Depression Rating Scale, Seasonal Affective Disorders
version (SIGH-SAD).
RESULTS: Data were analyzed as change from baseline.
SIGH-SAD-P total depression scores were significantly
decreased from baseline during light therapy compared with
placebo (one-way analysis of variance, rho = .009), and no
differences were found between the placebo and control
phases. Subscores of atypical and typical depression were
also significantly decreased during the active treatment
(rho = .004 and .028, respectively). A similar trend was
noted with the SIGH-SAD-C, but this did not reach
significance. At the end of the study, 78% of the parents
questioned and 80% of the children questioned rated light
therapy as the phase during which the child "felt
best."
CONCLUSION: Light therapy appears to be an effective
treatment for pediatric SAD.
[Melatonin and seasonal
depression]
Tarquini B; Perfetto F; Tarquini R Istituto di Clinica
Medica IV, Universita, Firenze.
Recenti Prog Med (Italy) Jul-Aug 1998 , 89 (7-8)
p395-403
Melatonin (MEL) hypothesis in seasonal affective
disorders (SAD) is supported by: a) historical hint; b)
circadian and seasonal MEL periodicity with evidence that
the SAD is related to photoperiod; c) relationship between
incidence and severity of SAD and latitude; d) the response
to bright artificial light (ineffective in depression)
which mimics summer time; e) MEL administration can induce
some symptoms of the SAD; f) several antidepressant drugs
increase MEL plasma levels. Several of these findings are
disproved: the light acts independently from the MEL, some
antidepressant agents act without modifying MEL levels; a
consistent alteration in MEL secretion within SAD has not
been convincingly demonstrated. Relationship between
incidence and severity of SAD and latitude suggests a new
potential implication of MEL in SAD. The daytime melatonin
values reflect changes along the scale of a year in
sunshine. Accordingly, the about-yearly periodicity, much
larger in amplitude than the half-yearly component, yields
ratios smaller than unity. By contrast during darkness an
about-half-yearly component is more prominent. As the
aurora zone is approached, the intensity of magnetic
disturbances increases. Thus, the intensity of these two
variables shows inverse relationships with latitude and
geomagnetic field decreases plasma levels of MEL and
inhibits MEL function. (38 Refs.)
A controlled trial of
timed bright light and negative air ionization for
treatment of winter depression.
Terman M, Terman JS, Ross DC Department of Psychiatry,
Columbia University, New York State Psychiatric Institute,
New York 10032, USA mt12@earthlink.com
Arch Gen Psychiatry 1998 Oct;55(10):875-82
BACKGROUND: Artificial bright light presents a promising
nonpharmacological treatment for seasonal affective
disorder. Past studies, however, have lacked adequate
placebo controls or sufficient power to detect group
differences. The importance of time of day of
treatment--specifically, morning light superiority--has
remained controversial.
METHODS: This study used a morning x evening light
crossover design balanced by parallel-group controls, in
addition to a nonphotic control, negative air ionization.
Subjects with seasonal affective disorder (N = 158) were
randomly assigned to 6 groups for 2 consecutive treatment
periods, each 10 to 14 days. Light treatment sequences were
morning-evening, evening-morning, morning-morning, and
evening-evening (10,000 lux, 30 min/d). Ion density was 2.7
x 10(6) (high) or 1.0 x 10(4) (low) ions per cubic
centimeter (high-high and low-low sequences, 30 min/d in
the morning).
RESULTS: Analysis of depression scale percentage change
scores showed low-density ion response to be inferior to
all other groups, with no other group differences. Response
to evening light was reduced when preceded by treatment
with morning light, the sole sequence effect. Stringent
remission criteria, however, showed significantly higher
response to morning than evening light, regardless of
treatment sequence.
CONCLUSIONS: Bright light and high-density negative air
ionization both appear to act as specific antidepressants
in patients with seasonal affective disorder. Whether
clinical improvement would be further enhanced by their use
in combination, or as adjuvants to medication, awaits
investigation.
SUGGESTED
READING
Sunny hospital rooms
expedite recovery from severe and refractory
depressions.
Beauchemin KM; Hays P University of Alberta, 1E7.31
Mackenzie Health Sciences Centre, Edmonton, Alberta,
Canada.
J Affect Disord (Netherlands) Sep 9 1996, 40 (1-2)
p49-51
Bright light therapy is an effective treatment for
seasonal affective disorder, an uncommon condition marked
by mild winter depression. Bright lights have been used as
adjuncts in the pharmacological treatment of other types of
depressive illness. The rooms in our psychiatric inpatient
unit are so placed that half are bright and sunny and the
rest are not. Reasoning that some patients were getting
light therapy inadvertently, we compared the lengths of
stay of depressed patients in sunny rooms with those of
patients in dull rooms. Those in sunny rooms had an average
stay of 16.9 days compared to 19.5 days for those in dull
rooms, a difference of 2.6 days (15%): P < 0.05.
5-Hydroxytryptophan: a
clinically-effective serotonin precursor.
Birdsall TC. 73541.2166@compuserve.com
Altern Med Rev 1998 Aug;3(4):271-280
5-Hydroxytryptophan (5-HTP) is the intermediate
metabolite of the essential amino acid L-tryptophan (LT) in
the biosynthesis of serotonin. Intestinal absorption of
5-HTP does not require the presence of a transport
molecule, and is not affected by the presence of other
amino acids; therefore it may be taken with meals without
reducing its effectiveness. Unlike LT, 5-HTP cannot be
shunted into niacin or protein production. Therapeutic use
of 5-HTP bypasses the conversion of LT into 5-HTP by the
enzyme tryptophan hydroxylase, which is the rate-limiting
step in the synthesis of serotonin. 5-HTP is well absorbed
from an oral dose, with about 70 percent ending up in the
bloodstream. It easily crosses the blood-brain barrier and
effectively increases central nervous system (CNS)
synthesis of serotonin. In the CNS, serotonin levels have
been implicated in the regulation of sleep, depression,
anxiety, aggression, appetite, temperature, sexual
behaviour, and pain sensation. Therapeutic administration
of 5-HTP has been shown to be effective in treating a wide
variety of conditions, including depression, fibromyalgia,
binge eating associated with obesity, chronic headaches,
and insomnia.
Prediction of acute and
late responses to light therapy from vocal (pitch) and
self-rated activation in seasonal affective
disorder.
Boenink AD; Bouhuys AL; Beersma DG; Meesters Y
Department of Biological Psychiatry, University Hospital of
Groningen, The Netherlands.
J Affect Disord (Netherlands) Feb 1997, 42 (2-3)
p117-26
It was hypothesized that pre-treatment activation plays
a role in the response to light therapy in Seasonal
Affective Disorder (SAD). In 55 SAD patients (DSMIII-R)
energetic and tense activation was assessed before light
therapy via self-rating (AD-ACL) and voice sound
characteristics (mean pitch and variation in pitch). These
variables were studied in relation to the "acute" response
to 4 days of light therapy (30 min, 10000 lux) and to a
"late" response (11 (10) days after light therapy had
stopped). Acute response was defined as the percent change
in 3 times daily self-rated depressed mood (AMS) with
respect to the average of 4 baseline days. "Late" response
was defined as the percent change in HRSD or AMS scores
between baseline and 11 (10) days after light therapy. It
was found that patients having high pitched voices with
small variation in this pitch benefitted more from light
therapy than the patients with low pitch and large
variation in pitch levels. This effect was only significant
after the first day of light exposure. No other significant
relations were found between baseline activation and acute
or late responses to light therapy. Hence, light therapy
seems to give extra comfort in "tense" patients, who become
rapid responders to light therapy.
Cluster headache and
periodic affective illness: common chronobiological
features.
Costa A; Leston JA; Cavallini A; Nappi G University
Centre for Adaptive Disorders and Headache (UCADH), Section
of Pavia I, Italy.
Funct Neurol (Italy) Jul-Sep 1998 , 13 (3) p263-72
Many of the seasonal changes occurring in animals appear
to be associated with photoperiodic modifications, and
particularly with the duration of the phases of exposure to
light and dark. The integration of these processes is made
possible by the normal functioning of biological
oscillators or synchronizers, presumably located at the
hypothalamic level. Cluster headache (CH), seasonal
affective disorder (SAD) and bipolar mood disorders are
conditions bearing numerous analogies, particularly as
regards the temporal pattern of disturbances, the nature of
predisposing or precipitating factors, the peculiar
relationship with sleep, the neuroendocrine findings, and
the clinical response to current treatments. The secretion
of melatonin, which is influenced by the light/dark cycle,
displays a bimodal pattern, which is likely to be dictated
by the activity of distinct synchronizers for light and
dark. Changes in the secretory pattern of this neurohormone
have also been documented in both CH and SAD. The
possibility of normalizing the secretory rhythm of
melatonin by means of phototherapy in SAD, and the
therapeutic use of the hormone to prevent the recurrence of
active phases in CH, represent further interesting
similarities between these two disorders. Melatonin, acting
as a unique neuroendocrine transductor of photic inputs,
may therefore be viewed as a marker of dyschronic disease
to be used in patients suffering from CH and affective
illness, for both diagnostic purposes and to assess the
response to pharmacological and non pharmacological
treatments. (47 Refs.)
The importance of full
summer remission as a criterion for the diagnosis of
seasonal affective disorder.
Danilenko KV; Putilov AA Institute of Physiology,
Siberian Branch of the Russian Academy of Medical Sciences,
Novosibirsk, Russia.
Psychopathology (Switzerland) 1996, 29 (4) p230-5
From 1987 to 1994, seasonal affective disorder (SAD) has
been diagnosed using the Rosenthal or DSM-III-R criteria.
No major differences between them have been found, except
that the DSM-III-R criteria were more stringent and
difficult to implement. Little attention has been paid to
differences in the criterion of the quality of improvement
in summer. This study compared two groups of winter
depressives characterized by complete or incomplete summer
remission. Incomplete summer remission is associated with
increased heterogeneity of the demographic and clinical
profile of the disorder and a shift of this profile to that
of classical depression. The data support clinical use of
the DSM-IV criterion 'full remission' in the diagnosis of
SAD.
[Phototherapy in
psychiatry: clinical update and review of
indications]
Gross F; Gysin F Clinique de Psychiatrie II,
Institutions universitaires de Psychiatrie, Geneve,
Suisse.
Encephale (France) Mar-Apr 1996, 22 (2) p143-8
Phototherapy introduced in 1984 by Rosenthal as a
treatment for SAD (Seasonal Affective Disorder) is the
first therapeutic answer to season-related psychopathology.
Findings in chronobiology have largely contributed to
pathophysiological theories of disorders in the internal
circadian system. Actual researches on the etiology of SAD
covers fields as retinal deficiency (i.e. disorder of
photoreceptors), phase disturbance of the internal
circadian rhythms given by internal oscillators and
neuroendocrinologically drived disorders, supposing that
melatonin is the main mediator of human circadian systems
in the CNS. Disorders of the neurotransmitters are an other
explored cue. Recent longitudinal studies show a prevalence
of seasonal depressive symptoms in general population up to
10%. In populations treated for depression the prevalence
of SAD is up to 20%. The SAD sex-ratio (women/men) of 3/1
is found repeatedly. Above 55 years SAD get rare.
Effectiveness of phototherapy is showed in nearly all
controlled studies. Bright light for patients with mild SAD
appears to be most effective as is also the authors
clinical impression through the practice of phototherapy in
Geneva since 1991. A true placebo for bright light is still
to be found according to enable evaluation of potentially
important impact that unspecific therapeutic factors may
trigger in phototherapy. Actually possible new indications
for phototherapy are being explored: bright light for non
seasonal depression has been tested with features with SAD;
effectiveness in bulimia has been suggested and recently
sleep disorders in pn improved. Nonseasonal circadian
disorders such as jet lag might be sensitive to light.(37
Refs.)
Natural bright light
exposure in the summer and winter in subjects with and
without complaints of seasonal mood
variations.
Guillemette J; Hebert M; Paquet J; Dumont M Laboratoire
de chronobiologie, Hopital du Sacre-Coeur de Montreal,
Quebec, Canada.
Biol Psychiatry (United States) Oct 1 1998 , 44 (7)
p622-8
BACKGROUND: Considering the success of bright light
therapy in seasonal affective disorders, it was suggested
that seasonal mood disorders are triggered by decreased
exposure to bright light in the winter; however, no
previous studies have used objective measures to assess
seasonal patterns of bright light illumination in subjects
with seasonal mood variations.
METHODS: Eleven subjects reporting seasonal mood
variations and 8 control subjects had their levels of
natural bright light (BL) exposure measured for 5-6 days
with an ambulatory monitor during both the summer and
winter, at a latitude of 45 degrees 31'N.
RESULTS: Both groups received significantly more BL in
the summer than in the winter, but there was no difference
between the two groups for the pattern of BL exposure,
including total duration, daily distribution, and amplitude
of seasonal variation.
CONCLUSIONS: These results suggest that complaints of
seasonal mood variations are not caused by a differential
pattern in bright light exposure compared to normals. It is
possible, however, that some individuals are more sensitive
than others to variations in natural bright light. Whether
an increased vulnerability is due to a more fragile
affective state or to a lower sensitivity to light remains
to be determined.
Pharmacological
treatment of seasonal affective disorder - The role of
hypericum extract
Kasper S. Prof. S. Kasper, Klin. Abt. Allgemeine
Psychiatrie, Universitatsklinik fur Psychiatrie, Wahringer
Gurtel 18-20, A-1090 Wien Austria
Psychopharmakotherapie, Supplement (Germany) 1998, 5/8
(21-25)
Seasonal affective disorder (SAD) is a subgroup of major
depression and characterized by a regular occurrence of
symptoms in autumn/winter and full remission or hymonia in
spring/summer. Light therapy (LT) and recently
pharmacotherapy with specific antidepressants have been
shown to be beneficial. Within the array of pharmacotherapy
hypericum extract has also been found to be effective in a
single-blind study. In this 4-weeks-treatment study 900 mg
of hypericum extract LI 160 was associated with a
significant reduction in the total score of the Hamilton
Depression Rating Scale. There was no significant
difference when bright light therapy was combined with
hypericum extract, compared to the situation without bright
light therapy. Overall, hypericum extract was well
tolerated and therefore the data suggest that
pharmacological treatment with hypericum may be an
efficient therapy in patients with SAD, which needs to be
substantiated in further controlled studies.
Side effects of
short-term 10,000-lux light therapy.
Kogan AO, Guilford PM Borgess Medical Center, Kalamazoo,
Mich., USA.
Am J Psychiatry 1998 Feb;155(2):293-4
OBJECTIVE: Previous reports of side effects from light
therapy were mostly based on administration of 2,500-lux
treatments. It has become common practice to use brighter,
10,000-lux exposure when treating seasonal affective
disorder. The authors studied side effects produced by
short-term 10,000-lux light therapy.
METHOD: Seventy subjects with seasonal affective
disorder who underwent brief 10,000-lux light therapy were
asked to report side effects.
RESULTS: Of the 70 subjects, 32 (45.7%) experienced side
effects, and nine (12.9%) reported two or more apiece.
Headaches and eye or vision problems were the most common.
Almost all were mild, were transient, and did not interfere
with treatment.
CONCLUSIONS: Short-term 10,000-lux light therapy often
produces side effects early in treatment. These are not
serious or prolonged, however, confirming findings from
earlier studies that used dimmer light.
Light treatment for
nonseasonal depression: speed, efficacy, and combined
treatment.
Kripke DF Department of Psychiatry, University of
California, San Diego, La Jolla 92093-0667, USA
dkripke@ucsd.edu
J Affect Disord (Netherlands) May 1998 , 49 (2)
p109-17
BACKGROUND: Using bright light for treating major
depressive disorders which are not seasonal needs
reassessment.
METHODS: Clinical trials of light treatment for
nonseasonal major depressive disorders were compared with
selected trials of light treatment of winter depression and
with antidepressant clinical drug trials.
RESULTS: Light treatment of nonseasonal depression
produces net benefits in the range of 12-35%, often within
1 week.
CONCLUSIONS: Light's value for nonseasonal and seasonal
depression are comparable. Light appears to produce faster
antidepressant benefits than psychopharmacologic
treatment.
LIMITATIONS: Direct randomizing comparisons between
light and medications for nonseasonal depression are not
available.
CLINICAL RELEVANCE: Bright light can be combined with
standard therapies for treating nonseasonal depressions and
appears synergistic.
Dawn simulation vs.
lightbox treatment in winter depression: a comparative
study.
Lingjaerde O, Foreland AR, Dankertsen J Department of
Research and Education, Gaustad Hospital, Oslo, Norway.
Acta Psychiatr Scand 1998 Jul;98(1):73-80
Dawn simulation, with gradually increasing bedside light
in the morning, has shown promising results as an
alternative to bright light treatment for winter
depression. To compare these treatments, 61 out-patients
with winter depression (20-70 years of age, 80% women) were
randomized to receive either lightbox treatment with
1500-2500 lux white light for 2 h in the morning for 6 days
on an out-patient basis (n=34), or dawn simulation
treatment in their homes, with 60 or 90 min of light
augmentation time to 100-300 lux, for 2 weeks (n=27).
Patients' ratings of improvement on a visual analogue scale
(correlating strongly with percentage reduction in an
extended Montgomery-Asberg Depression Rating Scale (MADRS)
score) at the end of treatment showed a mean of 40.0% (SD
27.7%) in the dawn simulation group and 57.4% (SD 29.9%) in
the lightbox group (P=0.02). The majority of the patients
in both groups maintained their improvement during a 9-week
follow-up. Age, sex, current major depression or current
use of antidepressants did not predict outcome in either
group. No serious side-effects were observed.
Extrapineal melatonin
and exogenous serotonin in seasonal affective
disorder
Partonen T. T. Partonen, Department of Psychiatry,
University of Helsinki, Tukholmankatu 8 C, FIN-00290
Helsinki Finland
Medical Hypotheses (United Kingdom) 1998, 51/5
(441-442)
Visible light inhibits the binding of melatonin and
serotonin to cultured human peripheral blood mononuclear
leukocytes (PBMLs) in winter. The decreased binding
switches the metabolism in PBMLs towards serotonin
synthesis, resulting in the reduced production of
melatonin. The ingestion of L-tryptophan during the day is
hypothesized to increase the levels of melatonin, released
from the gastrointestinal tract, in patients with winter
seasonal affective disorder (SAD). Due to the relative
shortage of light, coincident with a predisposed metabolic
error, there would be no switch towards serotonin synthesis
among winter SAD patients in winter. The rate of serotonin
synthesis could thus remain inadequately low to maintain
optimal mood in winter SAD patients.
Greater improvement in
summer than with light treatment in winter in patients with
seasonal affective disorder.
Postolache TT; Hardin TA; Myers FS; Turner EH; Yi LY;
Barnett RL; Matthews JR; Rosenthal NE Clinical
Psychobiology Branch, NIMH, Bethesda, MD 20892, USA
postolache@nih.gov
Am J Psychiatry (United States) Nov 1998 , 155 (11)
p1614-6
OBJECTIVE: The authors sought to compare the degree of
mood improvement after light treatment with mood
improvement in the subsequent summer in patients with
seasonal affective disorder .
METHOD: By using the Seasonal Affective Disorder Version
of the Hamilton Depression Rating Scale, the authors rated
15 patients with seasonal affective disorder on three
occasions: during winter when the patients were depressed,
during winter following 2 weeks of light therapy, and
during the following summer. They compared the three
conditions by using Friedman's analysis of variance and the
Wilcoxon signed ranks test.
RESULTS: The patients' scores on the depression scale
were significantly higher after 2 weeks of light therapy in
winter than during the following summer.
CONCLUSIONS: Light treatment for 2 weeks in winter is
only partially effective when compared to summer. Further
studies will be necessary to assess if summer's light or
other factors are the main contributors to this
difference.
Disorders of the
sleep-wake cycle in adults.
Sedgwick PM Department of Addictive Behaviour, St
George's Hospital Medical School, London, UK.
Postgrad Med J (England) Mar 1998 , 74 (869) p134-8
Adults have an intrinsic body clock which regulates a
complex series of rhythms including sleep and wakefulness,
fatigue and cognitive ability. This endogenous clock
naturally runs more slowly than the solar day and is
entrained to a 24-h rhythm primarily by the alternation of
light and darkness. Jet lag, shift-work sleep disorder, and
some of the chronic insomnias are caused by a temporal
discrepancy of the body clock relative to the surrounding
environment and social network. The underlying mechanisms
and general management are described. Both bright light and
melatonin therapy have potential in the management of these
disorders. Traditionally, bright light therapy has been
used to alleviate the depression associated with seasonal
affective disorder . Melatonin has received much ill-formed
publicity, it being claimed that it is a panacea and an
'antiageing' treatment. Both of these treatment approaches
are reviewed. (30 Refs.)
Platelet serotonergic
functions and light therapy in seasonal affective
disorder.
Stain-Malmgren R; Kjellman BF; Aberg-Wistedt A
Department of Psychiatry, Institution of Clinical Science,
Karolinska Institute, St. Goran's Hospital, Stockholm,
Sweden.
Psychiatry Res (Ireland) May 8 1998 , 78 (3) p163-72
We investigated platelet 14C-serotonin uptake and
platelet [3H]LSD and [3H]paroxetine binding in 11 patients
with seasonal affective disorder (SAD). Patients were
reinvestigated after light therapy, applied at 07.00-09.00
h for 10 consecutive days. The degree of depression was
rated before and after light therapy using the
Comprehensive Psychopathological Rating Scale (CPRS).
Baseline data in patients were compared with data from a
control group consisting of 11 age- and sex-matched healthy
volunteers. Seven patients responded to light therapy with
a > 50% reduction in CPRS scores. In non-responders,
the reduction in CPRS was 24.7 +/- 5.5%. There was a
significant inverse correlation (P = 0.014) between Km for
platelet 14C-serotonin uptake and CPRS scores. Patients had
significantly higher Bmax for platelet [3H]LSD binding (P =
0.04) and significantly lower Bmax for platelet
[3H]paroxetine binding (P = 0.016). There was a strong,
multiple correlation between Bmax for [3H]LSD, as the
dependent variable, and Km, Vmax and Bmax for
[3H]paroxetine binding in patients (P < 0.0001) but
not in controls. Responders to light therapy had
significantly higher Km (P = 0.023) and significantly lower
Bmax for [3H]paroxetine binding (P = 0.028) than
non-responders. Bmax for [3H]paroxetine binding increased
significantly to normal levels after light therapy. The
results indicate that SAD is associated with aberrations in
the serotonin uptake mechanism. The enhanced 5-HT2-receptor
density may reflect a consequential up-regulation.
Predictors of response
and nonresponse to light treatment for winter
depression.
Terman M; Amira L; Terman JS; Ross DC Department of
Psychiatry, Columbia University, New York, USA.
Am J Psychiatry (United States) Nov 1996, 153 (11)
p1423-9
OBJECTIVE: The authors' goal was to determine whether
the pattern and severity of depressive symptoms predict
response to light treatment for seasonal affective
disorder.
METHOD: Subjects with winter depression (N = 103) were
given bright light treatment. Seventy-one were classified
as responders, 15 as nonresponders, and 17 as partial
responders. Using depression rating scale data and
correlational and multivariate analysis, the authors sought
predictors of response in baseline symptom and scale
scores.
RESULTS: Responders were characterized by atypical
symptoms, especially hypersomnia, afternoon or evening
slump, reverse diurnal variation (evenings worse), and
carbohydrate craving. By contrast, nonresponders were
characterized mainly by melancholic symptoms, retardation,
suicidality, depersonalization, typical diurnal variation
(mornings worse), anxiety, early and late insomnia,
appetite loss, and guilt. The ratio of atypical to
classical symptoms of depression, rather than severity per
se, best predicted treatment outcome for the group as a
whole. treatment expectations were positively correlated
with improvement on the Hamilton Depression Rating Scale
but not on a supplementary scale of atypical symptoms.
CONCLUSIONS: Light-responsive seasonal affective
disorder is distinguished by a dominant atypical symptom
profile closely associated with depressed mood.
Nonresponders from a clinically distinct group with
melancholic features. The patient's symptom profile,
therefore, should be considered when diagnosing seasonal
affective disorder and selecting treatment.
Seasonal affective
disorder and season-dependent abnormalities of melatonin
suppression by light.
Thompson C, Stinson D, Smith A Department of Psychiatry,
University of Southamptom, Royal South Hants Hospital,
UK.
Lancet (1990 Sep 22) 336(8717):703-6
Twelve patients with seasonal affective disorder (SAD)
and eleven normal controls were exposed to 2000 lux and 300
lux of artificial full-spectrum light on consecutive nights
during the winter. Suppression of melatonin secretion under
the two light intensities was measured and the difference
between their effects was taken as a measure of light
sensitivity. The test was repeated in summer in both
groups, when the SAD subjects were well. The SAD but not
the normal group showed a significant seasonal variation in
sensitivity to light. There was evidence of
supersensitivity in the winter but also of subsensitivity
to light in the summer.
'Natural' light
treatment of seasonal affective disorder.
Wirz-Justice A; Graw P; Krauchi K; Sarrafzadeh A;
English J; Arendt J; Sand L Psychiatric University Clinic,
Basel, Switzerland.
J Affect Disord (Netherlands) Apr 12 1996, 37 (2-3)
p109-20
Patients with seasonal affective disorder (SAD) were
treated for 1 week either with a daily 1-h morning walk
outdoors (natural light) or low-dose artificial light (0.5
h@2800 lux). The latter treatment (given under double-blind
conditions) can be considered mainly placebo and did not
improve any of the depression self-ratings, whereas natural
light exposure improved all self-ratings. According to the
Hamilton depression score, 25% remitted after low-dose
artificial light and 50% after the walk. Sleep duration or
timing were not crucial for the therapeutic response. The
morning walk phase-advanced the onset and/or offset of
salivary melatonin secretion, but individual clinical
improvement could not be correlated with specific
phase-shifts. Morning cortisol was decreased. Low-dose
artificial light did not modify melatonin or cortisol
patterns. This is the first study to provide evidence for
the use of outdoor light exposure as a potential
alternative or adjuvant to convential light therapy in
SAD.
|