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Bright light therapy and/or imipramine for inpatients with recurrent non-seasonal depression

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The aim of a double-blind study was to assess the efficacy of bright light therapy and/or imipramine in the treatment of inpatients suffering with recurrent non-seasonal major depressive disorder. 34 in-patients with DSM-III-R diagnosis of major depressive disorder, recurrent type, were randomly allocated into 3 treatment groups. After 4-day washout period with baseline assessment they underwent 3 weeks of different types of treatment: a) Group A: bright light therapy (5000 lux from 6-8 a.m.) and imipramine 150 mg/day. b) Group B: bright light therapy (5000 lux from 6-8 a.m.) and imipramine-like placebo. c) Group C: dim red light (500 lux from 6-8 a.m.) and imipramine 150 mg/day. Outcome measures included weekly Hamilton Psychiatric Rating Scale for Depression, Clinical Global Impression Scale, Montgomery and Asberg Psychiatric Rating Scale for Depression and Beck Depression Inventory. Patients of all three groups improved significantly. The improvement of the patients of group B treated with bright light therapy plus placebo was superior to the other two groups, but not significantly. Bright light therapy can be effective in the treatment of non-seasonal major depressive disorder.
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109
Neuroendocrinology Letters ISSN 0172–780X
Copyright © 2002 Neuroendocrinology Letters
Bright Light Therapy and/or Imipramine for Inpatients
with Recurrent Non-Seasonal Depression
Jan Prasko, Jiri Horacek, Jan Klaschka, Jirina Kosova, Ivana Ondrackova &
Jiri Sipek
Head of the Psychiatric Centre Prague: Prof. MUDr. Cyril Höschl, DrSc.
Psychiatric centre Prague, Ustavni 91, Prague – 8, 181 03 Czech Republic
3rd Medical faculty Charles University Prague, Centre of Neuropsychiatric Studies
Correspondence to: Jan Prasko, M.D., Ph.D.
Psychiatric centre Prague, Ustavni 91, Prague – 8, 181 03 Czech Republic.
TEL +420-2-66003 100
FAX + 420-2-66003366
E-MAIL: prasko@pcp.lf3.cuni.cz
Submitted: January 19, 2002
Accepted: January 23, 2002
Key words: Major depressive disorder; inpatients; bright light therapy;
imipramine; combination, clinical trial
Neuroendocrinology Letters 2002; 23:109–113 pii: NEL230202A04 Copyright © Neuroendocrinology Letters 2002
Abstract INTRODUCTION: The aim of a double-blind study was to assess the efcacy of
bright light therapy and/or imipramine in the treatment of inpatients suf-
fering with recurrent non-seasonal major depressive disorder.
METHOD: 34 in-patients with DSM-III-R diagnosis of major depressive disor-
der, recurrent type, were randomly allocated into 3 treatment groups. After
4-day washout period with baseline assessment they underwent 3 weeks of
different types of treatment:
a) Group A: bright light therapy (5000 lux from 6–8 a.m.) and imipramine
150 mg/day.
b) Group B: bright light therapy (5000 lux from 6–8 a.m.) and imipra-
mine-like placebo.
c) Group C: dim red light (500 lux from 6–8 a.m.) and imipramine 150
mg/day.
Outcome measures included weekly Hamilton Psychiatric Rating Scale for
Depression, Clinical Global Impression Scale, Montgomery and Asberg Psy-
chiatric Rating Scale for Depression and Beck Depression Inventory.
RESULTS: Patients of all three groups improved signicantly. The improve-
ment of the patients of group B treated with bright light therapy plus pla-
cebo was superior to the other two groups, but not signicantly.
CONCLUSION: Bright light therapy can be effective in the treatment of non-
seasonal major depressive disorder.
O R I G I N A L A R T I C L E
110
Introduction
Depression is a common disorder, with serious con-
sequences for a high proportion of patients. Indeed, it
is estimated that 2.6 – 6.2% of the general population
experience depression in any given year [1] and that
15% of those who develop severe and recurrent illness
eventually take their own lives [2]. Unfortunately, al-
though ranges of effective antidepressant agents are
available, many require an administration period of at
least 2 weeks, and some up to 4 weeks, before a thera-
peutic effect is seen [3]. Bright light is a unique treat-
ment method, which is effective and well tolerated and
has an early onset of action, in the treatment of pa-
tients with Seasonal affective disorder [4, 5]. Some
studies reported an antidepressant effect of bright light
also in non-seasonal depression (non-SAD) [6, 7, 8].
However, the reports concerning the effect of a short-
term administration of bright light on non-SAD de-
pression are controversial. The aim of our double-blind
study was to compare the effect of a three week bright
light therapy and/or imipramine in the treatment of
inpatients suffering with recurrent non-seasonal major
depressive disorder.
Subject and Methods
Patients admitted to the clinical psychiatric in-pa-
tient department of the Psychiatric Centre Prague
were screened by an experienced psychiatrist for meet-
ing DSM-III-R diagnostic criteria for recurrent major
depressive disorder [9]. The diagnosis was independ-
ently conrmed by two independent experienced psy-
chiatrists.
The inclusion criteria:
1) Age 20–60 years.
2) Meeting the DSM-III-R diagnostic criteria for recur-
rent major depressive disorder of moderate or se-
vere type (296.32 and 296.33) without seasonal pat-
tern.
3) At least 2 episodes of major depression in life time,
and at least one episode of major depression dur-
ing the last 2 years previous the current episode; at
least one episode in another season than the current
one.
4) Total score of the 21-item Hamilton Psychiatric Rat-
ing Scale for Depression [10] higher than 20.
5) Written informed consent.
Exclusion criteria:
1) The presence of any of the following mental condi-
tions:
a. Bipolar depression
b. Panic disorder.
c. Alcoholism or drug abuse.
d. Antisocial personality disorder.
e. Histrionic personality disorder.
f. History of schizophrenia.
g. Organic brain impairment.
h. Mental retardation.
2) Presence of specic physical illness or medical con-
traindications for using imipramine; endocrine dis-
ease in history.
3) Pregnancy.
4) Treatment by drugs causing depression in the last
month.
5) Eye diseases (such as the aphakic condition, reti-
nal diseases, inammatory diseases, glaucoma, cata-
racts and optic nerve disease).
Patients were randomly assigned into three groups
with different treatment strategies. Each type of treat-
ment was administered for 21 consecutive days after 4
days of a placebo period. The groups were:
a) Group A: bright light therapy (5000 lx from 6–8
a.m.) and imipramine 150 mg/day.
b) Group B: bright light therapy (5000 lx from 6–8
a.m.) and imipramine-like placebo.
c) Group C: dim red light (500 lx from 6–8 a.m.) and
imipramine 150 mg/day.
Light specications:
a) Bright-light: 5 000 lx (14 cool white uorescent
tubes, DAYLIGHT Tesla) on a portable box.
b) Dim red-light: 500 lx (3 cool white uorescent tubes,
DAYLIGHT Tesla and red lter), on a portable
box.
Main outcome measures:
Outcome measures included baseline and weekly
evaluation by 21-item Hamilton Psychiatric Rating
Scale for Depression (HAMD) [10], Clinical Global Im-
pression Scale (CGI) [11], Montgomery and Åsberg
Psychiatric Rating Scale for Depression (MADRS) [12],
and Beck Depression Inventory (BDI) [13]. We used
Czech version of scales [14]. HAMD, CGI and MADRS
were rated by an independent psychiatrist.
Statistical analysis:
The data were analysed by the analysis of variance
with repeated measures (ANOVA; Software BMDP)
[15]. For each scale a separate analysis was performed
comparing the raw scores in the three groups during
the four measurements periods. The parameter of
major interest was the interaction between the treat-
ment groups and time.
Results
Thirty-four newly admitted in-patients with mean
age 42.6 (SD=10.3), 12 male and 22 female were ran-
domly allocated into 3 treatment groups. Twenty-nine
patients completed the study and there were 5 drop-
outs (group A:11 nished and 2 drop-outs, group B:
9 nished and 2 drop-outs, group C:9 nished and 1
drop-out) (Table 1). There are no signicant differ-
ences in the demographic characteristics of patients
(age, gender, numbers of previous depressive episodes,
duration of illness, education, employment) between
the groups. The drop-outs did not stand out as to de-
mographic variables or the severity of illness. All drop-
outs appeared during the rst week of study. Two pa-
Jan Prasko, Jiri Horacek, Jan Klaschka, Jirina Kosova, Ivana Ondrackova & Jiri Sipek
111
Neuroendocrinology Letters ISSN 0172–780X Copyright © 2002 Neuroendocrinology Letters
Non-Seasonal Depression and BLT
Table 2: Characteristics of patients completing
the study
The analysis of variance with repeated measures
for each scale separately showed statistically signi-
cant changes over time in all three treatment groups
(HAMD p<0.01; BDI p<0.01; MADRS p<0.01 and
CGI-severity of illness p<0.01). The plot of mean
group scores against time showed that the improve-
ment in the patients of the group B (bright light ther-
apy plus placebo) was superior to that of the group
A (bright light and imipramine) in BDI (two-way
ANOVA: p<0.05), CGI (p<0.005), HAMD (p<0.05),
MADRS (p<0.01) (Table 2). There were no statistical
differences in the outcome of treatment between the
groups B (bright light therapy plus placebo) and C
(imipramine and dim red light) in any of the ratings
except for BDI in favour of the group B (ANOVA:
p<0.05). Using the criteria of Terman et al. [5], who
denes the response to bright light therapy by a 50%
reduction in HAMD to a value less than 8, we found
that 4 patients (36.4%) responded to treatment in the
A group, 6 (66.7%) responded in the B group, and 3
(33.3%) responded in the C group.
Table 1. Characteristics of patients completing the study
N mean gender mean number of
age male:female previous episodes
of depression
Group A 11 41.0 + 9.3 3:8 4.0 + 1.4
Group B 9 44.1 + 11.6 4:5 3.5 + 0.8
Group C 9 43.2 + 10.9 3:6 3.8 + 1.2
Total 29 42.6 + 10.3 10:19 3.8 + 1.2
Table 2. Median BDI, HAMD, CGI and MADRS ratings in three treatment groups
A (n=11) B (n=9) C (n=9) Two-way analysis of variance
Outcome Period (BLT+IMI) (BLT+PLAIMI) (DRL+IMI) with repeated measures
Measure Mean SD Mean SD Mean SD
BDI Day 0 32.9 11.5 34.2 10.3 31.8 12.2 A v. B v. C: F=2.25 p < 0.05
Day 7 30.5 11.4 23.1 13.3 29.7 13.2 A v. B: F=3.10 p < 0.05
Day 14 26.2 14.4 19.6 10.8 27.0 12.7 B v. C: F=2.86 p < 0.05
Day 21 24.8 14.7 15.0 9.9 22.3 10.9 A v. C: n.s.
HAMD Day 0 23.0 6.4 23.1 3.6 24.7 3.8 A v. B v. C: n.s.
Day 7 21.0 7.3 15.7 7.8 22.6 6.3 A v. B: F=3.31 p < 0.05
Day 14 15.5 8.3 14.0 7.7 18.7 8.6 B v. C: n.s.
Day 21 17.0 11.2 8.7 5.8 13.0 7.9 A v. C: n.s.
CGI Day 0 4.36 0.92 4.67 0.71 4.33 0.71 A v. B v. C: F=3.42 p < 0.005
Day 7 3.82 1.33 3.78 1.20 3.89 0.93 A v. B: F=5.54 p < 0.005
Day 14 3.18 1.17 3.22 1.09 3.22 0.83 B v. C: n.s.
Day 21 3.45 1.51 2.00 1.00 2.67 0.87 A v. C: n.s.
MADRS Day 0 27.6 7.9 26.2 5.8 27.1 5.6 A v. B v. C: F=2.52 p < 0.05
Day 7 24.1 9.2 18.0 9.5 22.1 6.8 A v. B: F=4.36 p < 0.01
Day 14 16.7 8.4 17.1 10.2 17.2 8.5 B v. C: n.s.
Day 21 18.4 12.0 8.7 5.4 12.4 7.9 A v. C: n.s.
PLAIMI = imipramine-like placebo
BLT = bright light therapy
IMI = imipramine
DRL = dim red light
A = group A
B = group B
C = group C
v. = versus (comparing with)
BDI = Beck Depression Inventory
HAMD = 21-item Hamilton Psychiatric Rating Scale for Depression
CGI = Clinical Global Impression Scale Severity of Illness
MADRS = Montgomery and Asberg Psychiatric Rating Scale for Depression
tients (one of the group A and one of the group B)
developed hypomania. They remained euthymic for a
week after discontinuing bright light therapy. Two pa-
tients (one of the group A and one of the group C)
dropped out due to adverse side effects of the treat-
ment (both suffered from typical anticholinergic ef-
fects of imipramine), and one patient of the group B
dropped out due to non-compliance.
112
Fig. 1. Beck Depression Inventory
Fig. 2. Hamilton Rating Scale for Depression
Jan Prasko, Jiri Horacek, Jan Klaschka, Jirina Kosova, Ivana Ondrackova & Jiri Sipek
Discussion
The data suggest that the 3 weeks application of
morning bright light without additional pharmacother-
apy could be an effective short-term treatment for pa-
tients with recurrent unipolar major depressive disor-
der without seasonal pattern. The efcacy of bright
light therapy alone was comparable with that of the
imipramine treatment, and surprisingly better than
the combination of bright light and imipramine. Our
present results corroborate and extend previous nd-
ings about the efcacy of bright light therapy in non-
seasonal depressive disorder [7, 8]. Why the combined
therapy is less effective than each treatment alone is a
question open to further investigation. This result con-
trasts with our previous ndings which suggested an
acceleration of the effect of antidepressants by using
phototherapy in endogenous depression. In that earlier
study we used, however, other antidepressants, mostly
amitriptyline. It is possible that different results we ob-
tained now were due to a different effect of distinct an-
tidepressants used in combination with the light treat-
ment. We cannot rule out a placebo effect. Possible
placebo effect of bright light therapy was described by
Eastman [16] in patients with seasonal affective disor-
der. However, if the efcacy of treatment by bright light
and placebo was mainly due to a placebo effect of bright
light, why we did not observe this in the group treated
by bright light and imipramine? Another problem is
that dim light is not physiologically active in humans.
In such instances red light with intensity 500 lux would
not be an appropriate light-placebo control. To clarify
these questions further long-term, follow-up trials, in-
cluding an untreated (i.e. negative) or a true placebo
control groups are needed.
Acknowledgment
Supported by grant CNS LN00B12 MSMT CR and
by grant IGA: 870-2.
113
Neuroendocrinology Letters ISSN 0172–780X Copyright © 2002 Neuroendocrinology Letters
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Fig. 3. Clinical Global Impression Severity of Illness
Fig. 4. Montgomery and Åsberg Rating Scale for Depression
Non-Seasonal Depression and BLT
... The median sample sizes were, respectively for each group, 18 (range 4e48), 26 (range 9e48), and 20 (range 4e54). The majority of participants were outpatients except in the study of Benedetti el al. (2003) and Prasko et al. (2002), with seasonal or non-seasonal MDD and BD (see Table 1). Participants were all diagnosed according to DSM criteria: older studies used DSM-III-R and the most recent DSM-IV-TR. ...
... LT þ AD versus LT þ placebo AD We did not observe any difference in depressive scores between the LT þ AD and the LT þ placebo AD, with a SMD of 0.19 CI95% [-1.1 -1.4] (z ¼ 0.30, p ¼ 0.77). Of note, only two studies were eligible for this meta-analyses [11,35] and results yielded great heterogeneity (I 2 ¼ 82.72%), thus the interpretation of this result is very limited. See Fig. 5. ...
... The type of antidepressant which should be used in combination with LT also warrants closer examination. This meta-analysis included studies that mostly assessed SSRIs (6/7), with only one assessing tricyclics [35]. Post-hoc meta-analysis excluding the Prasko et al. study that used tricyclics increased the effect size of the combination LT þ AD versus AD þ placebo LT, with a significant SMD in favor of LT þ AD of 0.68 CI 95% [0.39e0.97] ...
... First, Schuchardt et al. [25], compared bright light (5000 lux-hours, daytime, wavelength not described) to dim light in 40 patients receiving fluoxetine, and saw a larger antidepressant response following bright light. Similarly, a second study of 29 patients found that three weeks of bright light (10,000 morning lux-hours, "cool white fluorescent") led to equivalent depressive symptomology decrease as imipramine treatment (by 9.1 and 6 HAM-D points, respectively), and that more patients in the BLT group responded (50% decrease in HAM-D score to a score <8) to treatment (66.7%) than did patients in either the imipramine group (33.3%) or the combination bright light and imipramine group (36.4%) [26]. Sertraline was also found to be effective in combination with BLT, with a significantly larger treatment response (50% decrease in HAM-D score to score <8) found in patients receiving bright light (10,000 morning lux-hours, "bright white fluorescent") than of those receiving dim light, over the course of bright light treatment [27,28]. ...
... In contrast, some studies have not supported the efficacy of adding bright light as an adjuvant to ADMs. First, as noted above, Prasko and colleagues found that bright light alone produced a greater benefit than bright light combined with imipramine [26]. Similarly, Muller et al. [31], found no group differences between trimipramine monotherapy, and trimipramine plus bright light (10,000 evening lux-hours). ...
... Nine studies, spanning 1985e2013, investigated the use of BLT as a stand-alone treatment for depression (Table 1B). Additionally, three of the studies discussed previously investigated at least one stand-alone BLT group; one [15] which found the treatment to be beneficial, though not as beneficial as a combination of bright light and fluoxetine, another [30] which found no additional benefit of an ADM in addition to BLT, and the third [26] which found that stand-alone bright light was actually more effective than a combination of bright light and ADM (imipramine). ...
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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.
... 15 Prasko et al obtained conflicting results, finding that after a short treatment period of 3 weeks, 2 hours of 5000 lux LT on its own was more effective than the combination of LT and imipramine, a tricyclic antidepressant. 16 So, LT seems efficient alone or in combination with antidepressant. Moreover, LT might potentiate the action of antidepressant drugs, accelerate treatment response and reduce the time to remission. ...
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Worldwide, individuals are living longer due to medical and scientific advances, increased availability of medical care and changes in public health policies. Consequently, increasing attention has been focused on managing chronic conditions and age-related diseases to ensure healthy aging. The endogenous circadian system regulates molecular, physiological and behavioral rhythms orchestrating functional coordination and processes across tissues and organs. Circadian disruption or desynchronization of circadian oscillators increases disease risk and appears to accelerate aging. Reciprocally, aging weakens circadian function aggravating age-related diseases and pathologies. In this review, we summarize the molecular composition and structural organization of the circadian system in mammals and humans, and evaluate the technological and societal factors contributing to the increasing incidence of circadian disorders. Furthermore, we discuss the adverse effects of circadian dysfunction on aging and longevity and the bidirectional interactions through which aging affects circadian function using examples from mammalian research models and humans. Additionally, we review promising methods for managing healthy aging through behavioral and pharmacological reinforcement of the circadian system. Understanding age-related changes in the circadian clock and minimizing circadian dysfunction may be crucial components to promote healthy aging.
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The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inner-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
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Bright artificial light has been found effective in reducing winter depressive symptoms of Seasonal Affective Disorder, although conclusions about the true magnitude of treatment effect and importance of time of day of light exposure have been limited by methodologic problems. Individual subjects' data from 14 research centers studying 332 patients over 5 years were analyzed with a pooled clustering technique. Overall, 2500-lux intensity light exposure for at least 2 hours daily for 1 week resulted in significantly more remissions--Hamilton Depression Rating Scale (HAM-D) score reduction of 50% or more to a level under 8--when administered in the early morning (53%) than in the evening (38%) or at midday (32%). All three times were significantly more effective than dim light controls (11%). Dual daily exposures (morning-plus-evening light) provided no benefit over morning light alone. In morning-evening crossovers, remission rates were 62% under morning light alone, compared with 28% under evening light alone, with a differential morning-evening response present in 59% of morning responders compared with 10% of evening responders (p less than 0.001). Remission rates with morning light were highest given low severity at baseline (HAM-D score of 10-16: 67% remission), as compared with moderate-to-severe cases (HAM-D score above 16: approximately 40% remission) where no morning-evening differences were found. Firmer conclusions await treatment studies with larger sample sizes and full assessment of atypical vegetative symptoms seen in winter depression but underrepresented in the Hamilton scale. Longer treatment course and greater light intensity may help clarify clinical response despite the impossibility of achieving a conventional blind placebo control.
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The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inter-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
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Review of the published literature produces 1-year prevalence rates for major depressive disorder DSM-III between 2.6 and 6.2%, for dysthymia between 2.3 and 3.7%, bipolar disorder 1.0-1.7%. Data from the prospective Zurich Study with four interviews over 10 years give relatively high 10-year prevalence rates for subjects from age 20 to 30 (14.4% major depression, 10.5% recurrent brief depression, 0.9% dysthymia, 3.3% bipolar disorder, 1.3% hypomania). On average, 49% of all these cases received treatment for affective disorder, resulting in a weighted treatment prevalence rate of the population of 11.6% (18% for females and 5% for males). It has to be assumed that lifetime prevalence rates based on recall may greatly underestimate true morbidity.
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Psychotropic drug-free hospitalized veterans with nonseasonal major depressive disorders or depressed forms of bipolar disorder were treated with light for 1 week. Twenty-five patients were randomly assigned to bright white light treatment (2000-3000 lux), and 26 patients were randomized to dim red light placebo control treatment. Unlike those treated with dim red light, those treated with bright white light showed declines in three measures of depression during treatment. Partial relapse appeared within 2 days. A global depression score showed a statistically significant (p = 0.02) difference favoring bright white light treatment. Two bright-light-treated patients became mildly hypomanic, but side effects were mild. Improvement was not correlated with patient expectations; indeed, patients expected somewhat greater benefit from the placebo. Patients treated in summer responded as well as those treated in winter. Baseline electroencephalogram (EEG) sleep stage data (e.g., rapid eye movement; REM latency) did not predict treatment responses. These 1-week treatment results suggest that bright light might produce benefits for patients with nonseasonal depression. Bright light should not be recommended for routine clinical application before additional assessments with longer treatment durations are done.
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Objective and subjective quality of sleep and awakening as well as circadian rhythms in cortisol, temperature and well-being were investigated in 10 female hospitalized depressed patients diagnosed as major depressive disorders according to RDC criteria before (baseline), during (intervention) and after (recovery) treatment with biologically active or bright light (BL) and were compared with the findings in 10 normals. Polysomnographic evaluation demonstrated in depressed patients an increased sleep latency, decreased total sleep time, attenuated S4 and augmented REM sleep, as well as a shortened REM latency and a statistically significant increased average REM length as compared with normals. BL tended to shorten sleep onset, decrease number of awakenings, increase REM latency and significantly attenuated the average REM length. Subjective sleep quality tended to improve as did the subjective awakening quality after the recovery night. There was, however, a statistically significant improvement of the objectively evaluated quality of awakening and early morning behavior characterized by an improved attention, reaction time and performance in the reaction time task, while concentration and psychomotor activity tended to improve as as well. BL effects were also seen in hormonal secretion patterns: circadian cortisol secretion maxima occurred earlier in depressed patients than in normals before and after BL treatment, while during BL intervention this difference disappeared. Circadian temperature rhythms did not exhibit any significant findings with the exception of an earlier occurring minimum in depressed patients than in normals after treatment. Finally, subjective well-being as rated by means of an analogue scale was significantly worse in depressed patients than normals before but not during and after light treatment. The findings are discussed.