Review article
Light therapy for older patients with non-seasonal depression: A systematic review and meta-analysis

https://doi.org/10.1016/j.jad.2018.02.041Get rights and content

Highlights

  • This review suggested that light therapy is more effective than control therapy in decreasing depression score of older adults.

  • Our study included six studies with few risk and bias make the results more accurate and credible compared with previous studies.

  • This review investigated the factors of light type, intervention time, light intensity and measured depression scale.

  • This review showed that the light type, the treatment time (3-week) and a certain range of light intensity have an influence on the effectiveness of treatment of depression.

  • This review firstly confirmed that different light therapies which measured by various depression scales have different effective treatment for depression.

Abstract

Background

Light therapy has become an increasingly common treatment for adults with depression, yet the role of light therapy for non-seasonal depression among older adults remains unclear.

Objective

This meta-analysis sought to evaluate the effectiveness of light therapy among older patients with non-seasonal depression.

Methods

We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science, CNKI and CBM from the inception of each database to May 2017. Two researchers conducted the literature screening, data extraction, and methodological quality assessment independently. We used the Cochrane Collaboration's bias assessment tool to evaluate the risk of bias for included studies, and Review Manager 5.2.3 Software for the meta-analysis.

Results

Six trials with a total of 359 patients were included, and five studies were assessed as being of low risk for bias. We evaluated the effect of light therapy on depression by the reduction of depressive symptoms (SMD = 0.45; 95% CI= [0.14, 0.75]). The subgroup analysis did not find significant moderating effects of depression with intervention intensity, light type, measuring scale or intervention duration.

Limitations

Most of the study samples were not representative of the larger population of adults and therefore caution should be used when interpreting the findings.

Conclusions

Light therapy has a positive effect on geriatric non-seasonal depression. Studies with larger sample sizes are needed to confirm the curative effect of light therapy in the future.

Introduction

Depression is a common mental disorder affecting about 350 million people globally (Marcus et al., 2012). Depressive symptoms include feelings of sadness and/or hopelessness, loss of interest in most normal activities, change in appetite, sleep disturbances, tiredness and lack of energy, feelings of worthlessness and/or guilt, trouble concentrating, and suicidal ideation (Association, 2013). Trailing only heart disease, depression will become the second leading cause of disability globally by the year 2020 (Murray and Lopez, 1996). In addition, one study reported that approximately 60% of individuals with severe depression commit suicide (Cavanagh et al., 2003).

The first-line treatment for addressing geriatric depression includes psychological treatments, such as behavioral activation, cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT; Cuijpers et al., 2013; Wilson et al., 2008). Medical interventions are also common place, such as selective serotonin reuptake inhibitors, electroconvulsive therapy (ECT), and tricyclic antidepressants). However, these treatments have several limitations. For example, ECT showed medical-related adverse effects (Mark et al., 2011) and psychotherapy tends to have poor treatment adherence and lack of consistent conclusion of its efficacy (Lynch et al., 2010, Parker and Fletcher, 2007). Moreover, research found that about 50–60% of patients adopted the first-line approaches (i.e., psychological treatments) for depression, and among these psychologically treated patients, only 35–40% experienced remission of symptoms during an 8-week trial of antidepressants because of their unwanted medical-related side effects (Connolly and Thase, 2011, Fava, 2003). Therefore, it is necessary to further investigate the effects of alternative or combined interventions to improve depressive symptoms.

Light therapy is an alternative treatment for seasonal affective disorder (SAD) by stabilizing circadian melatonin secretion and improving monoaminergic function in the central nervous system. It is often delivered through a light box that is equipped with fluorescent tubes, and a reflector or diffusing screen (Pail et al., 2011a, Pail et al., 2011b, Rosenthal et al., 1984, Terman and Terman, 2005). A study with more than 70 clinical trials (Lam et al., 2006) and several international recommendations and guidelines suggest that light therapy is an acceptable treatment option for seasonal depression (Anderson et al., 2008, Bauer et al., 2007, Listed, 2000, National Collaborating Centre for Mental, 2010, Ravindran et al., 2016). In addition, three systematic reviews and meta-analyses of studies with individuals of all ages (Even et al., 2008, Golden et al., 2005, Tuunainen et al., 2004) showed that the light therapy had impacts on both seasonal and non-seasonal depression.

The idea of using light therapy for depression arose from basic research showing that exposure to light could alter circadian rhythms and suppress melatonin secretion in humans by activating the suprachiasmatic nucleus and the circadian pacemaker of the brain. It has been found that light therapy positively affects mood, sleep, circadian rhythms, and hypothalamic-pituitary-adrenal axis activity in patients with SAD, which is one type of seasonal depression (Knapen et al., 2014, Lewy et al., 1980, Martensson et al., 2015, Oldham and Ciraulo, 2014, Westrin and Lam, 2007). However, the precise functional mechanism of light therapy in the treatment of depression remains unclear (Pail et al., 2011a, Pail et al., 2011b).

The effects of light therapy are influenced by various factors, such as light types and intensity, illumination duration, intervening objects, and interference factors. Terman et al. (2005) found that the strength of light is associated with the therapeutic effects, and high light treatment is superior to low light in reducing depression symptoms (Rosen et al., 1990). In addition, a randomized study of 50 patients with seasonal depression confirmed the relationship that one month of light intervention has significant effects on geriatric seasonal depression (Rastad et al., 2008). However, these studies have limitations, including small sample sizes and low quality of study design (e.g., non-experimental), and therefore more evidence is needed to confirm their conclusions.

Several recent systematic reviews evaluated the efficacy of light therapy on depression, yet the conclusions were inconsistent. Martensson and colleagues (2015) confirmed bright light therapy was a well-established treatment for seasonal depression, but they did not perform a meta-analysis of the two included studies for non-seasonal depression. Al-Karawi and Jubair (2016) showed that bright light therapy appears to be efficacious for non-seasonal depression. Perera et al. (2016) pointed out that light therapy has minimal side-effects for non-seasonal depression in adults over the age of 18. However, the quality of evidence was poor because of the high risk of bias and heterogeneity in samples across the included studies. In addition, the above mentioned reviews were not focused on geriatric non-seasonal depression. Given the newly-published high-quality and comparative studies comparing light therapy with other interventions on non-seasonal depression, it is necessary to assess the effectiveness of light therapy for non-seasonal depression among older patients.

Section snippets

Search strategy

Literature searches were carried out with six electronic databases, including the Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), and Chinese Biomedical Literature database (CBM). The search included articles published from the inception year of each database to May 2017. Key words used in the searching include “aged,” “aging,” “elderly,” “old* ,” “geriatric,” “depress* ,” “light* ,” and “phototherapy”. Text terms

Study identification and selection

Initially, 726 studies were found using the search terms from all the six databases. After screening the titles and abstracts and removing irrelevant articles and duplicates, 31 articles were included to screen via full-text. A total of 25 studies were excluded because they: were conference abstract (n = 8), combined other therapy with light therapy (n = 2), had unavailable data (n = 10), were not RCT in design (n = 2), were research project plans (n = 2), or compared light therapy differences

Discussion

The aim of this study was to systematically review the effects of light therapy for non-seasonal geriatric depression. We found that light therapy is an effective treatment for reducing the depression symptoms among older adults. The subgroup analysis of six included studies showed that light treatment time, light intensity in a specified range and light types influenced the effect of light therapy, even when there were no statistical significant differences between intervention and control

Conclusion

This systematic review suggests that light therapy is an effective treatment for non-seasonal depression. In addition, the subgroup analysis showed that light treatment time, light intensity in a specified range, measuring scale, and light types were potentially influential factors of light therapy for geriatric non-seasonal depression, even without statistical significant differences. Moreover, this review indicates that there were no severe side effects between the light treatment and placebo

Acknowledgements

This work was supported by Central College Basic Scientific Research Business Expenses of Lanzhou University [grant number 16LZUJBWTD013]; and Central College Basic Scientific Research Business Expenses Special Funding of Lanzhou University [grant number LZUJBKY-2016-69]. The authors thank all patients, practice nurses, and investigators for their contributions to this study.

Disclosure

This article has not been published elsewhere in whole or in part. All authors have read and approved the comment and agree to submit for consideration for publication on the journal.

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