Review articleLight therapy for older patients with non-seasonal depression: A systematic review and meta-analysis
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.
References (50)
- et al.
Bright light therapy for nonseasonal depression: meta-analysis of clinical trials
J. Affect. Disord.
(2016) - et al.
Cornell scale for depression in dementia
Biol. Psychiatry
(1988) - et al.
Random-effects model for meta-analysis of clinical trials: an update
Contemp. Clin. Trials
(2007) - et al.
Efficacy of light therapy in nonseasonal depression: a systematic review
J. Affect. Disord.
(2008) Diagnosis and definition of treatment-resistant depression
Biol. Psychiatry
(2003)- et al.
The duration of light treatment and therapy outcome in seasonal affective disorder
J. Affect. Disord.
(2014) - et al.
Antidepressant use in geriatric populations: the burden of side effects and interactions and their impact on adherence and costs
Am. J. Geriatr. Psychiatry.: Off. J. Am. Assoc. Geriatr. Psychiatry.
(2011) - et al.
Bright white light therapy in depression: a critical review of the evidence
J. Affect. Disord.
(2015) - et al.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
J. Clin. Epidemiol.
(2009) - et al.
Light room therapy effective in mild forms of seasonal affective disorder--a randomised controlled study
J. Affect. Disord.
(2008)
Prevalence of seasonal affective disorder at four latitudes
Psychiatry Res.
Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines
J. Psychopharmacol. (Oxf., Engl.)
Diagnostic and Statistical Manual of Mental Disorders: DSM-5
World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders in primary care
World J. Biol. Psychiatry.: Off. J. World Fed. Soc. Biol. Psychiatry.
Psychological autopsy studies of suicide: a systematic review
Psychol. Med.
If at first you don't succeed: a review of the evidence for antidepressant augmentation, combination and switching strategies
Drugs
A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments
Can. J. Psychiatry
Bias in meta-analysis detected by a simple, graphical test
BMJ (Clin. Res. Ed.)
The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence
Am. J. Psychiatry
A rating scale for depression
J. Neurol., Neurosurg., Psychiatry
Cochrane Handbook for Systematic Reviews of Interventions
The Can-SAD study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder
Am. J. Psychiatry
Light suppresses melatonin secretion in humans
Science (New York, N.Y.)
Bright light treatment in elderly patients with nonseasonal major depressive disorder: a randomized placebo-controlled trial
Arch. General. Psychiatry
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