Light Box Therapy for Depression, Sleep Disorders, and Other Problems

In addition to its extensive use in the treatment of Seasonal Affective Disorder (SAD), bright light therapy has been shown to be useful in the treatment of several other kinds of problems:
	Circadian rhythm sleep disorders (SEE SLEEP DISORDERS PAGE) Clinical depression Bulimia nervosa Sleep and agitation in dementia and Alzheimer's disease Premenstrual syndrome (PMS) Regulating menstrual cycles in women with winter depression Depression in pregnancy and postpartum depression

Preliminary studies have also been conducted on the use of light therapy for a variety of other psychiatric and medical problems including alcoholism, obesity, immune function, obsessive-compulsive disorder, panic disorder and chronic fatigue syndrome.

TREATMENT: Bright light therapy recommended by researchers and clinicians for most people is 10,000 lux for 30 minutes per day. An alternative treatment would be 2,500 lux for at least 2 hours. Because light diminishes with distance, lux is measured at a specific distance away from a light source. For light therapy devices, this distance is measured from the user's eyes. The best lights for bright light therapy are metal fixtures containing white fluorescent light bulbs behind a diffuser, and tilted forward so that the light is angled downward, permitting more light to enter the eyes and decreasing the apparent brightness of the light, in turn creating less glare and improving user comfort.

Light Box Therapy for Depression

Shortly before the hype began about bright light therapy being an effective treatment for Seasonal Affective Disorder (SAD), pilot studies had been conducted on the use of bright light for non-seasonal major depression including bulimia treatment, PMS treatment and relief, manic depression treatment and more.

These preliminary studies were inconclusive; therefore they did not generate the publicity that followed the initial studies on light treatment for SAD. We now know, from the SAD studies and studies on using light to treat circadian rhythm disorders, that the intensity of light in these initial studies was lower than the amounts found to be biologically active in humans. [1]

Subsequent studies on light treatment for non-seasonal depression, which have made use of the findings from SAD treatment, have shown overwhelmingly that bright light treatment successfully reduces depression scores by 12-35% for non-seasonal depression. Significant benefit is often noted within one week or less. [2] Strong evidence exists that bright light therapy can be used in conjunction with other therapies, such as antidepressants and partial sleep deprivation. In fact, the benefit of such combined treatments may be greater than the sum of the effects of the separate treatments. [3,4] Benefit with bright light is often seen within the first week, but additional benefit is seen over the next several weeks. [5] "Extended treatment beyond four weeks has not been studied systematically, but clinical experience indicates that many depressed patients benefit from incorporating bright light into their long-term living patterns." [6]

It has been suggested that longer exposure times might be required for those with non-seasonal depression than for those with SAD, as this group may be less sensitive to bright light. [7] However, patients taking psychiatric medications (e.g., tricyclics, tetracyclics, lithium) may be at increased risk of complications, as these medications cause photosensitivity, so extreme caution should be exercised, and such patients should be closely monitored by their health professionals when undertaking light therapy. [8]

It has been suggested that several groups of non-seasonally depressed people may particularly benefit from bright light treatment. Elderly people, especially those in community-living residences, often are exposed to little or no bright light, and may experience problems with their circadian rhythms as well as depression. With the abundance of medications this population already take, the side effects and interactions of many medications, and the fact that hypnotic medications are often of little or no value to this age group, [9] bright light treatment may be the optimal treatment for both their circadian rhythm disorders and their depression. [10]

Since light treatment is a non-pharmacologic treatment, it may be better tolerated in patients who decline medication treatment due to side effects, compliance issues, or drug intolerance. [11] For those with adolescent-onset bipolar disorder, light therapy could be a useful adjunct to other treatments. [12]

TREATMENT: Bright light therapy for depression requires a minimum of 2,500 lux to be effective, and the brightness recommended by researchers and clinicians for most people is 10,000 lux for 30 minutes per day.

Light Box Therapy for Bulimia Nervosa

Many women with bulimia nervosa have marked winter worsening of both mood and binge/purge symptoms, and light therapy has been shown to be beneficial for both symptom groups. [13]

TREATMENT: Interestingly, there appear to be different thresholds for response of the mood symptoms—which respond more rapidly and robustly—than the binge/purge symptoms. Therefore, a longer treatment time might be required to affect the binge/purge symptoms, even when the depressive symptoms respond to shorter treatment times. [14] "Lam et al have reported reductions in binge eating after 10,000 lux of light administered for 30 minutes per day in the early morning for 2 weeks." [15]

Light Box Therapy for Sleep and Agitation in Dementia and Alzheimer's Disease

Elderly people, especially those who are institutionalized, demented, and/or affected by Alzheimer's disease, receive very little bright environmental light compared to younger people. In addition, age-related changes in the visual system may influence the amount of perceived light, so that higher intensities are necessary to affect the same changes as would occur in younger persons. [16] Since bright environmental light is of central importance in stabilizing circadian (daily) rhythms, notably the sleep-wake cycle and the rest-activity cycle, this lower light exposure may contribute to sleep and performance problems. [17] In the nursing home setting, ambient light at night may contribute to increased nighttime activity, [18] disrupting the sleep of other residents.

Caregiving for adults with dementia and those with Alzheimer's disease is often difficult, and two of the primary problems leading to institutionalization is agitation during waking hours and restlessness during the night. [19,20,21] Increasing light exposure during the day, which has been shown to improve nocturnal sleep and improve agitation patterns—not eliminating the agitation, but changing the timing of it to more convenient times for the caregiver(s)—may be beneficial not only for improving the quality of life for the patient, but making caregiving easier may help to postpone the need for institutionalization. [22,23,24]

Without examining the effectiveness of the light treatment, one study examined the feasibility of administering light treatment to demented institutionalized patients. [25] The results indicated that light treatment can be administered to this population if patients are closely attended by staff during the treatments. However, since they tend to fall asleep frequently, treatment times may need to be extended to allow the patients to receive the full duration of treatment while awake. The feasibility of light treatment for this population is positive news, since use of medications with these patients often results in side effects which worsen their behavior and/or cognitive abilities. [26]

With Alzheimer's patients, especially those with sundowning behavior (agitation in the afternoon or evening), treatment with bright light is associated with improvement in the sleep-wake cycle, decreased nighttime activity, and improvement in sundowning behavior. [27] The severity of sundowning behavior before treatment appears to predict greater improvement after light treatment. [28]

TREATMENT: Timing of treatment varies among the various studies, with either 2 hours of morning light, 2 hours of evening light, or 1 hour of light exposure in both the morning and evening. Perhaps the best factor in determining timing for individuals in this population, since all of the above schedules have been shown to be helpful, is to examine the sleep cycles of the patients and determine if there is a phase shift, either advanced or delayed (see Sleep Disorders page) and timing the treatment appropriately so as to improve, rather than worsen, the sleep-wake cycle. If the sleep-wake cycle isn't a factor, then all three of the above schedules may be equally effective.

Light Box Therapy for Problems Related to the Menstrual Cycle:
Premenstrual Syndrome (PMS) and Regulating Cycle Length

Bright light treatment has been shown to be effective in reducing depressive symptoms related to premenstrual syndrome (PMS), also known as premenstrual dysphoric disorder (PMDD) or late luteal phase dysphoric disorder (LLPDD). [29,30,31] It has also been shown to reduce PMS symptoms, including physical symptoms. [32]

Dawn simulation has been shown to reduce the length of menstrual cycles in women with winter depression and to regulate the cycles. [33] This approach may prove useful for women whose menstrual cycles are either irregular or extremely long.

Light Box Therapy for Depression in Pregnancy and Post-Partum Depression

Treatment options for depressed pregnant women are limited. [34] Since research protocols often exclude pregnant women from medication studies, the safety of antidepressants for pregnant women and their babies is often not known. Many women, therefore, choose not to be on antidepressants during pregnancy. There is preliminary evidence that bright light therapy, since it is a non-pharmacological approach, is a safe alternative for depressed pregnant women and their babies. [35]

During the postpartum period, many women, especially those who are breastfeeding, also choose to avoid antidepressants. Again, bright light treatment, which has been shown to be effective, should be considered during this time. [36] This is a crucial time for the woman to get the treatment she needs to overcome her depression, since now—more than ever—she needs to be at her best.

TREATMENT: Bright light therapy for depression in pregancy and post-partum depression requires a minimum of 2,500 lux to be effective, and the brightness recommended by researchers and clinicians for most people is 10,000 lux for 30 minutes per day.

Possible Future Directions for Light Box Therapy:
Alcoholism, Obesity, Immune Functioning, Obsessive-Compulsive Disorder, Panic Disorder and Chronic Fatigue Syndrome

The list of disorders for which light treatment is currently used is impressive. Some researchers have suggested that we may be seeing only the tip of the iceberg when it comes to the range of applications for light treatment that future research may uncover. Preliminary studies have been conducted on the use of light therapy for a variety of psychiatric and medical problems not mentioned elsewhere on this website. However, the evidence for light treatment's effectiveness for the conditions mentioned here must be considered preliminary and weak. Only further clinical research will determine whether these applications will pan out.

According to Dr. Norman Rosenthal, "There have been a few studies suggesting that exposure to bright light during a period of withdrawal from alcohol may ease the feelings of anxiety, irritability and mood instability that are commonly experienced in such circumstances. A small pilot study suggests that light therapy may help obese people lose weight. Finally, exposure to bright light may influence immune functioning, though it has yet to be determined whether such an influence can be used for therapeutic purposes." [37]

Dr. Raymond Lam states that, "There is increasing interest in the concept of seasonality of psychiatric disorders. Seasonal Affective Disorder (SAD) has garnered the greatest attention, but seasonality has been examined in...obsessive-compulsive disorder, alcoholism, and panic disorder." [38] We know that seasonality predicts response to light therapy in both depression and bulimia. It make sense, then, to theorize that it may also predict response in these other psychiatric disorders.

A study of Chronic Fatigue Syndrome (CFS) patients, while not examining or even addressing the issue of light therapy, does indicate that circadian rhythms may be disrupted for patients with this disorder. [39] However, since we that light is one of the most powerful synchronizers of circadian rhythms [see Sleep Disorders page], it seems logical to suggest that bright light therapy may be a useful treatment for Chronic Fatigue Syndrome.

In the words of Dr. Lam, "Current evidence for therapeutic effects of light is substantial, the potential for future medical applications of light is enormous, and the increased research and clinical interest in light therapy appears well justified. The next decade in light research will no doubt provide more insights into basic mechanisms of light, as light becomes a standard treatment in our therapeutic armamentarium." [40]

Sources:
[1] Kripke, DF: Light treatment for non-seasonal depression: speed, efficacy, and combined treatment. J Affect Disord, 49: p 110, 1998.
[2] ibid, pp 111-112.
[3] Loving, RT: Bright light augmentation of antidepressant medication. Society for Light Treatment and Biological Rhythms Abstracts, 11: p 33, 1999.
[4] Kripke, pp 112 & 116.
[5] ibid, p 112.
[6] ibid.
[7] Papatheodorou, G & S Kutcher: The effect of adjunctive light therapy on ameliorating breakthrough depressive symptoms in adolescent-onset bipolar disorder. J Psychiatry Neurosci, 20(3): p 230, 1995.
[8] ibid, p 231.
[9] Campbell, SS, D Dawson & MW Anderson: Alleviation of sleep maintenance insomnia with timed exposure to bright light. J Am Ger Soc, 41(8): p 829, 1993.
[10] Martin, J, T Shochat & S Ancoli-Israel: Illumination and depression in elderly nursing home residents. Society for Light Treatment and Biological Rhythms Abstracts, 11: p 31, 1999.
[11] Thalén, B-E, BF Kjellman, L Mørkrid et al.: Light treatment in seasonal and non-seasonal depression. Acta Psychiatrica Scand, 91: p 352, 1995.
[12] Papathedorou, p 229.
[13] Lam, RW, EM Tam, A Grewal et al.: Light therapy for seasonal bulimia. Society for Light Treatment and Biological Rhythms Abstracts, 12: p 20, 2000.
[14] Blouin, AG, JH Blouin, H Iversen et al.: Light therapy in bulimia nervosa: a double-blind, placebo-controlled study. Psychiatr Res, 60(1): pp 6-8, 1996.
[15] Blouin, p 6.
[16] van Someren, EJW, EEO Hagebeuk, C Lijzenga et al.: Circadian rest-activity rhythm disturbances in Alzheimer's disease. Biol Psychiatry, 40: p 260, 1996.
[17] ibid, pp 260 & 266.
[18] Martin, J, T Shochat, PG Gehrman et al.: Light, sleep and agitation in Alzheimer's disease patients. Society for Light Treatment and Biological Rhythms Abstracts, 12: p 13, 2000.
[19] van Someren, p 260.
[20] Martin, 2000, p 13.
[21] Satlin, A, L Volicer, V Ross et al.: Bright light treatment of behavioural and sleep disturbances in patients with Alzheimer's disease. Am J Psychiatr, 149(8): p 1028, 1992.
[22] Ancoli-Israel, S: The effect of light on sleep, rhythms and behavior in Alzheimer's disease. Society for Light Treatment and Biological Rhythms Abstracts, 14: p 1, 2002.
[23] Martin, 2000, p 13.
[24] Lovell, BJ, S Ancoli-Israel, DW Jones et al.: The effect of bright light on agitation: case reports. Society for Light Treatment and Biological Rhythms Abstracts, 4: p 9, 1992.
[25] Pat-Horenczyk, R, J Martin, D Jones et al.: Feasibility of light treatment with demented nursing home patients. Society for Light Treatment and Biological Rhythms Abstracts, 8: p 34, 1996.
[26] Satlin, p 1028.
[27] ibid, p 1031.
[28] ibid.
[29] Parry, BL, AM Mahan, N Mostofi et al.: Light therapy of late luteal phase dysphoric disorder: an extended study. Am J Psychiatry, 150(9): p 1418, 1993.
[30] Lam, RW, D Carter, S Misri et al.: A controlled study of light therapy for premenstrual depression. Society for Light Treatment and Biological Rhythms Abstracts, 9: p 3, 1997.
[31] Parry, BL: Light therapy of premenstrual depression. Society for Light Treatment and Biological Rhythms Abstracts, 4: p 29, 1992.
[32] Lam, 1997, p 3.
[33] Danilenko, KV, NR Passynkova & SB Hayes: Dawn/dusk simulation in SAD - effects on menstrual cycle length, depression and comparison to bright light and reboxetine. Society for Light Treatment and Biological Rhythms Abstracts, 12: p 17, 2000.
[34] Oren, DA, KL Wisner, M Spinelli et al.: Morning light treatment for antepartum depression. Society for Light Treatment and Biological Rhythms Abstracts, 11: p 7, 1999.
[35] ibid.
[36] Corral, A Kuan & D Kostares: Bright light therapy for postpartum depression. Society for Light Treatment and Biological Rhythms Abstracts, 11: p 27, 1999.
[37] Rosenthal, NE: Winter Blues: Seasonal Affective Disorder - What It Is and How to Overcome It. (rev. ed.) New York: The Guilford Press, p 262, 1998.
[38] Lam, RW, EM Goldner & A Grewal: Seasonality of symptoms in anorexia and bulimia nervosa. Int J Eat Disord, 19(1): p 35, 1996.
[39] Williams, G, J Pirmohamed, D Minors et al.: Dissociation of body-temperature and melatonin secretion circadian rhythms in patients with chronic fatigue syndrome. Clin Physiol, 16: p 335, 1996.
[40] Lam, RW: Seasonal affective disorder and beyond: a commentary. In: Seasonal Affective Disorder and Beyond: Light Treatment for SAD and Non-SAD Conditions. Edited by Lam, RW. Washington, DC: American Psychiatric Press, p 319, 1998.

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