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Light-Therapy Applications for DSM-IV-TR Disease Entities

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Light-Therapy Applications for DSM-IV-TR Disease Entities Eur. J. Psychiat. Vol. 23, N.° 3, (166-176) 2009 Keywords: Seasonal affective disorder (SAD); Light therapy; Phototherapy. Light-therapy applications for DSM-IV-TR disease entities Mercedes Paino Eduardo Fonseca-Pedrero Manuel Bousoño Serafín Lemos-Giráldez Department of Psychology. University of Oviedo Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Ministry of Science and Innovation SPAIN ABSTRACT – Background and Objectives: Recent decades have seen significant ad- vances in the knowledge of pathogenesis of mood disorders, as well as of other conditions directly or indirectly related to such diseases. Such progress has led to the emergence of new treatments, such as bright light therapy, based on the discovery of the therapeutic ef- fects of exposure to bright light with the so-called seasonal affective disorder (SAD), a DSM seasonal pattern specifier linked to major depression and bipolar disorder recurrent describing the course of illness during seasons. The goal of the present work is to review the potential clinical applications of phototherapy, including SAD, obsessive-compulsive disorder, bulimia, premenstrual syndrome, non seasonal major depression, sleep disor- ders, jet-lag, dementia, normal populations and in primary care. Methods: A systematic review of the literature about this matter since the early Rosen- thal’s group observations has been carried out. Results: A considerable number of studies has been published about this therapeutic approach, pointing that not only depression but also other pathologies that may follow a seasonal pattern could benefit from phototherapy integrated with more standard treat- ments, as well as other disorders directly or indirectly related to mood, and even another conditions without a seasonal pattern. Conclusions: The data about the different uses of this treatment neither confirm nor dismiss its efficacy, stating that the therapy should still be regarded as experimental. Fu- ture studies should continue investigating to draw reliable conclusions about the useful- ness of bright light therapy on mood disorders and other conditions to provide an alterna- tive to standard treatments almost exclusively based on psychoactive drugs. Received 5 December 2008 Revised 16 May 2009 Accepted 8 June 2009 LIGHT THERAPY FOR DSM-IV-TR DISEASE ENTITIES 167 Seasonal affective disorder in countries such as the USA10, Japan11,Fin- (SAD) land12 and Australia13, as well as in samples from polar expeditions14 and from military personnel and their families15. The therapeutic effects of exposure to bright light are by no means a phenomenon of Numerous alternative explanations of the recent discovery.As early as the 1920s, thanks pathogenic mechanisms of SAD have been primarily to the work of Kraepelin1, attention proposed. The early theories receiving the was drawn to the presence of certain depres- most empirical support were those related to sive disorders which, in contrast to other af- a psychophysical alteration in light sensitiv- fective disorders, would begin in a more or ity due to a retinal or hypothalamic deficit16. less regular way in the autumn/winter, with re- But the discovery that treatment with bright mission in the spring/summer. These initial light improved depressive symptoms in observations led Rosenthal’s2 team to define such patients has led researchers to focus what was known as seasonal affective disor- their attention on the circadian system and der (SAD) or seasonal depression, after the regulatory role of melatonin in it for ex- demonstrating the antidepressant effect of ex- plaining not only the cause of the disorder posure to bright light in this type of patient3,4. but also the therapeutic mechanism of pho- Thus, the condition would consist in recurrent totherapy17,18. depressive episodes occurring annually, tend- ing this “winter” depression to be charac- terised by anergy, hypersomnia, hyperphagia, increased appetite, weight gain and compul- Light therapy sive consumption of carbohydrates5,6. The first symptoms of SAD usually occur By the 1990s, the effectiveness of treat- in adulthood, and the severity of the syn- ment with bright light for “winter depres- drome often increases with geographical lat- sion” had been described in over 30 con- itude2,7; it is more common in women, and trolled studies, with more than 300 patients in the age range 35 to 508. However, SAD is at 14 different research centres19; recent re- not considered as a separate diagnostic cate- views have confirmed the success of this gory: the DSM-III-R9 refers to “specifica- treatment20,21, due primarily to its rapid and tion of seasonal pattern” to apply to Bipolar well-tolerated antidepressant effect. disorders I and II and to Recurrent Major Depressive Disorder, the principal character- Numerous studies have used the Hamilton istic of this pattern being the onset and re- Depression Rating Scale-Seasonal Affective 22 mission of major depressive episodes at cer- Disorders Version (HDRS-SAD) in an ef- tain times of the year. fort to identify possible predictors of re- sponse to treatment. The results of these stud- Given the characteristics of SAD, the re- ies indicate that non-responders to treatment duction in exposure to daylight has been hy- with light for SAD displayed different clini- pothesised as its principal aetiological trig- cal profiles when they were depressed6,23,24, gering factor, based on population surveys with higher scores on the Hamilton scale and carried out from the 1990s onwards which lower scores on the complementary atypical explored changes in the prevalence of the symptoms scale; the more severe the atypical disorder in relation to geographical latitude symptoms of depression (i.e., hypersomnia, 168 MERCEDES PAINO ET AL. fatigability or carbohydrate craving) the a rectangular box32. Since then, there has more likely they were to respond to pho- been speculation as to whether full-spectrum totherapy, while greater severity of melan- light is actually an essential requirement for cholic (“endogenous”) symptoms (i.e., sui- the treatment of SAD33, leading to research cide, feelings of guilt, motor retardation, on the efficacy of different light spectra34-36, insomnia, anxiety, typical diurnal variation - including full-spectrum light with or without morning worse- or despersonalization) pre- ultraviolet rays, cool-white light (i.e., fluo- dict a poor response. Other studies have identified specific symptoms as potential rescent light with a substantial production of predictors of response to light therapy (see energy in the green and yellow wave bands, Table I), and a current research line attempts and a small quantity of ultraviolet emission), to relate personality variables and the re- red light, green light and incandescent light sponse to phototherapy25-27. (yellow waves with negligible ultraviolet emission). However, and in spite of consid- erable research efforts, the properties of the light spectrum most suitable for use in pho- Types of light totherapy for SAD have not yet been clearly identified, though it does seem to be clear The original design for research on pho- that ultraviolet wavelengths are not neces- totherapy with SAD used a system of full- sary for the antidepressant effect in SAD, so spectrum fluorescent bulbs, giving off light that, given its potentially harmful effects, it containing all the wavelengths of sunlight should not be used in phototherapy for this from behind a plastic diffusing screen inside disorder37. Table I Summary of predictor and non-predictor variables of respons to light treatment Study Predictors Non-predictors Oren et al.28 Hypersomnia Craving for carbohydrates Sucidal ideation Lam et al.29 Hypersomnia Increased ingestion Youth Kräuchi et al.30 High sweet intake late in the day Mood swings during the day Sleep-related symptoms Meesters et al.31 Diurnal variation Hypersomnia LIGHT THERAPY FOR DSM-IV-TR DISEASE ENTITIES 169 Clinical applications of light and well tolerated in patients with SAD, therapy achieving a rapid improvement of mood state and eating-disorder symptoms, as well as in patients with seasonal patterns of bu- 38 In the early 1990s, Rosenthal’s group set limia nervosa41,42, though in the case of out to explore the extent to which seasonali- these bulimic patients it is recommended ty might be a feature of other neuropsychi- that phototherapy be used in conjunction atric entities, and to study the effectiveness with other treatments of a pharmacological of light therapy for different disorders. From and/or psychological nature. then on, a range of studies have focused on the seasonal pattern and light-therapy appli- cations for diverse conditions: c) Premenstrual syndrome a) Obsessive-compulsive Premenstrual syndrome is characterised disorder (OCD) by cyclical mood changes that correspond to the menstrual cycle43, and it has been Initially, seasonal variation in the symp- shown how women with SAD frequently toms of 34 patients with OCD was also present premenstrual syndrome44,as explored38. Of these patients, who used a well as other common symptoms, such as retrospective self-report scale measuring over-sleeping, carbohydrate craving and mood and behavioural changes, a consider- lethargy2,43. Very recent studies with large able proportion with obsessive-compulsive samples of women with premenstrual syn- disorder (53%) reported a marked seasonal drome, moreover, have reported a reduction variation in their symptoms. Furthermore, in depressive symptoms and premenstrual evidence that serotoninergic
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