Light therapy has become established as an evidence-based treatment for Seasonal Affective Disord... more Light therapy has become established as an evidence-based treatment for Seasonal Affective Disorder. Light impacts the timing and stability of circadian rhythms as expressed in sleep, mood, alertness, and cognition. Forty years of clinical trials and open treatment have led to guidelines for patient selection, using light alone or in combination with antidepressants (or lithium for bipolar depression). Mood and sleep disturbances can also respond to adjunct light therapy in a broader set of psychiatric, neurologic and medical illnesses. We specify criteria for choice of treatment devices: optimum dose (10,000 lux), spectrum (white light), exposure duration (30-60 minutes) and timing (early morning). Protocol adjustment requires continual monitoring with attention to rate of improvement and management of potential side effects.
The Committee on Chronotherapeutics was recently formed by the International Society for Affectiv... more The Committee on Chronotherapeutics was recently formed by the International Society for Affective Disorders (ISAD), which has asked us to provide a consensus review of chronotherapeutics (light and wake therapy) in affective disorders. We consider these non-pharmaceutical, biologically based therapies to be potentially powerful adjuvants ready for clinical application. We also stress the need for additional studies, both in-patient and out-patient, to broaden the evidence base for indications and efficacy. The theme of adjuvant therapy is of increasing interest. Many of the lectures at the 2nd ISAD Meeting (Cancun, Mexico, March 2004) emphasized that combination treatments -such as cognitive behavioural therapy added to antidepressants -could help treat the residual symptoms that indeed portend relapse . The meeting highlighted expansion of interest in the development of new concepts for treating depressive illness (i.e. drug targets other than monoamines) -to wit : 'New antidepressants are needed and they are on their way ' . On a pragmatic plane, the World Health Organization (WHO) has placed emphasis on the 'need to demonstrate that interventions are not only effective and sustainable, but also affordable ' . The meeting symposia shared the realization that the long-sought, faster-acting, relapse-preventing antidepressants are still not at hand, and that the field must continue to pursue combinations of psychological and pharmacological interventions. Missing from discussion, however, was consideration of light therapy and sleep deprivation, whose well-demonstrated efficacy -alone or in combination -could fulfil the WHO mandates of affordability and sustainability. The apparent blindness to these treatments by the psychiatric mainstream most likely stems from the prevailing neuropharmacological paradigm, and -if we may face realities -the commercial drawback that they cannot be patented . In spite of many fascinating recent advances in development of new classes of antidepressant drugs , they are not yet ready for clinical use. By contrast, chronobiological interventions are already available and offer prospects no less potent than any candidate drug . Chronotherapeutics -treatments based on the principles of circadian rhythm organization and sleep physiology -offers mental health practitioners a set of non-pharmaceutical, rapid and effective antidepressant modalities for monotherapy or as adjuvants to conventional medication. Here, we consider supplemental light exposure and sleep deprivation (more positively known as 'wake therapy ') as first-line treatments for major depression. Light therapy was first developed and has been established as the treatment of choice for winter seasonal affective disorder (SAD ; Partonen & Magnusson, 2001). The use of light therapy has expanded beyond SAD , with evidence for efficacy in premenstrual ) and antepartum (Epperson et al. 2004) depression, bulimia nervosa (Blouin et al. 1996 ;, as well as sleep-wake cycle disturbances [delayed and advanced sleep phase syndromes ) and Alzheimer's dementia (Skjerve et al. Evidence for the usefulness of these treatments for non-seasonal major depression is less clear, with both positive and lack of effects on record. Most studies have been of much shorter duration than required for testing new antidepressants, even
The authors' previous experiments have shown that dawn simulation at low light intensities ca... more The authors' previous experiments have shown that dawn simulation at low light intensities can phase advance the circadian rhythm of melatonin in humans. The aim of this study was to compare the effect of repeated dawn signals on the phase position of circadian rhythms in healthy participants kept under controlled light conditions. Nine men participated in two 9-day laboratory sessions under an LD cycle 17.5:6.5 h, < 30:0 lux, receiving 6 consecutive daily dawn (average illuminance 155 lux) or control light (0.1 lux) signals from 0600 to 0730 h (crossover, random-order design). Two modified constant routine protocols before and after the light stimuli measured salivary melatonin (dim light melatonin onset DLMOn and offset DLMOff) and rectal temperature rhythms (midrange crossing time [MRCT]). Compared with initial values, participants significantly phase delayed after 6 days under control light conditions (at least –42 min DLMOn, –54 min DLMOff, –41 min MRCT) in spite of cons...
We investigated a possible mechanism of action for the antidepressant response to light-phase adv... more We investigated a possible mechanism of action for the antidepressant response to light-phase advances of the circadian clock-by measuring the onset of melatonin secretion before and after light treatment in the morning or evening. Methods: Plasma melatonin was sampled in 42 patients with seasonal affective disorder, in the evening or overnight while depressed and after 10 to 14 days of light therapy (10000 lux for 30 minutes) when symptoms were reassessed. Results: Morning light produced phase advances of the melatonin rhythm, while evening light produced delays, the magnitude depending on the interval between melatonin onset and light exposure, or circadian time (morning, 7.5 to 11 hours; evening, 1.5 to 3 hours). Delays were larger the later the evening light (r=0.40), while advances were larger the earlier the morning light (r=0.50). Although depression ratings were similar with light at either time of day, response to morning light increased with the size of phase advances up to 2.7 hours (r=0.44) regardless of baseline phase position, while there was no such correlation for evening light. In an expanded sample (N=80) with the sleep midpoint used as a reference anchor for circadian time, early morning light exposure was superior to late morning and to evening exposure. The antidepressant effect of light is potentiated by early-morning administration in circadian time, optimally about 8.5 hours after melatonin onset or 2.5 hours after the sleep midpoint.
Bright light therapy for seasonal affective disorder (SAD) has been investigated and applied for ... more Bright light therapy for seasonal affective disorder (SAD) has been investigated and applied for over 20 years. Physicians and clinicians are increasingly confident that bright light therapy is a potent, specifically active, nonpharmaceutical treatment modality. Indeed, the domain of light treatment is moving beyond SAD, to nonseasonal depression (unipolar and bipolar), seasonal flare-ups of bulimia nervosa, circadian sleep phase disorders, and more. Light therapy is simple to deliver to outpatients and inpatients alike, although the optimum dosing of light and treatment time of day requires individual adjustment. The side-effect profile is favorable in comparison with medications, although the clinician must remain vigilant about emergent hypomania and autonomic hyperactivation, especially during the first few days of treatment. Importantly, light therapy provides a compatible adjunct to antidepressant medication, which can result in accelerated improvement and fewer residual sympt...
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Papers by Michael Terman