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Light therapy

Profile image of Michael TermanMichael Terman

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https://doi.org/10.29172/F5025176-7B3C-435B-BC7E-231B608BFE9B
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Abstract

The susceptibility of the circadian system to selective phase shifting by timed light exposure has broad implications for the treatment of sleep-phase and depressive disorders. Light therapies have been devised that can normalize the patterns of delayed sleep phase syndrome (through circadian phase advances) and advanced sleep phase syndrome (through circadian phase delays). Doctors and patients need to become cognizant of the daily intervals when light exposure—and darkness—can facilitate or hamper adjustment. The primary intervals lie at the edges of the “subjective night,” which coincide with the tails of the nocturnal melatonin cycle, but they can be inferred clinically through a chronotype questionnaire. The lighting schedule may have to be continually adjusted as the subjective night shifts gradually in the desired direction. The treatment strategy for seasonal and nonseasonal depressive disorders is similar. In winter depression, the magnitude of phase advances correlates with the degree of mood improvement, and the optimum timing of light therapy must be specified relative to circadian rather than solar time. Apart from its use as a monotherapy, light therapy in both outpatient and inpatient trials indicates that light therapy accelerates remission of nonseasonal depression in conjunction with medication. Exploratory applications for treatment of antepartum and premenstrual depression, bulimia nervosa, sleep disruption of senile dementia, and shift work and jet lag disturbance are considered. The chapter provides the clinician with guidelines for selecting lighting apparatus based on safety, efficacy, and comfort factors; summarizes adverse effects of light overdose; and offers a straightforward protocol for selecting treatment time of day. Exposure of the eyes to light of appropriate intensity and duration, at an appropriate time of day, can have marked effects on the timing and duration of sleep and on the affective and physical symptoms of depressive illness. The most extensive clinical trials have focused on winter depression, or seasonal affective disorder (SAD). Here, we review and evaluate the application of light therapy for circadian rhythm sleep disorders including delayed sleep phase syndrome (DSPS), advanced sleep phase syndrome (ASPS), non–24-hour sleep phase syndrome, and the displaced sleep of shift work and jet lag. Beyond SAD, we also cover light therapy for nonseasonal depressions (recurrent, chronic, premenstrual, and antepartum), including combination treatment with wake therapy and medication; bulimia nervosa; and the sleep-wake problems of senile dementia. We describe the critical features of light delivery systems; safety factors and potential adverse effects; and timing and dose optimization for light administration, including a set of clinical case studies. (For a review of the underlying circadian physiology, see Terman.1)

Figures (8)
The susceptibility of the circadian system to selective phase shifting by timed light exposure has broad implications for the treatment of sleep phase and depressive disorders. Light therapies have been developed to normalize the patterns of delayed sleep phase disorder (through circadian phase advances) and advanced sleep phase disorder (through circadian phase delays). Physicians and patients need to be cognizant of the daily intervals when light exposure—and darkness—can facilitate or hamper adjustment to the desired circadian phase. The critical intervals lie at the edges of the subjective night, which coincide with the tails of the nocturnal melatonin cycle, but can be inferred clinically through a morn- The treatment strategy for seasonal and nonseasonal depression is similar. In winter depression, the size of circa- dian rhythm phase advances correlates with the degree of mood improvement, and the optimal timing of light therapy must be specified relative to the patient’s circadian clock rather than solar time. Apart from its use as a monotherapy, light therapy in outpatient and inpatient trials indicates that it accelerates remission of nonseasonal depression in conjunc- tion with antidepressant and mood-stabilizing medication.
The susceptibility of the circadian system to selective phase shifting by timed light exposure has broad implications for the treatment of sleep phase and depressive disorders. Light therapies have been developed to normalize the patterns of delayed sleep phase disorder (through circadian phase advances) and advanced sleep phase disorder (through circadian phase delays). Physicians and patients need to be cognizant of the daily intervals when light exposure—and darkness—can facilitate or hamper adjustment to the desired circadian phase. The critical intervals lie at the edges of the subjective night, which coincide with the tails of the nocturnal melatonin cycle, but can be inferred clinically through a morn- The treatment strategy for seasonal and nonseasonal depression is similar. In winter depression, the size of circa- dian rhythm phase advances correlates with the degree of mood improvement, and the optimal timing of light therapy must be specified relative to the patient’s circadian clock rather than solar time. Apart from its use as a monotherapy, light therapy in outpatient and inpatient trials indicates that it accelerates remission of nonseasonal depression in conjunc- tion with antidepressant and mood-stabilizing medication.
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Table 149-1 Timing of Morning Light Therapy* Based on Morningness—Eveningness Score *Start of 10,000-lux, 30-minute session, approximately 8.5 hours after estimated melatonin onset. Bold indicates the range confirmed in clinical trials. MEQ, Horne-Ostberg Morningness-Eveningness Questionnaire. Data from Terman M, Terman JS. Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects. CNS Spectr 2005;10:647-663.
Table 149-1 Timing of Morning Light Therapy* Based on Morningness—Eveningness Score *Start of 10,000-lux, 30-minute session, approximately 8.5 hours after estimated melatonin onset. Bold indicates the range confirmed in clinical trials. MEQ, Horne-Ostberg Morningness-Eveningness Questionnaire. Data from Terman M, Terman JS. Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects. CNS Spectr 2005;10:647-663.
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Patient J.M. (Fig.149-4) is male, age 28 years, and an accomplished scholar. He had experienced extreme delayed sleep phase disorder since adolescence. It was aggravated in recent years, with sleep onset around 7 AM and waking around 3 pM. The distinct downside for him was the inability to collaborate with colleagues during the normal workday. He resisted hypnotic medication but intermittently used alcohol to fall asleep a few hours earlier. Melatonin has been used as monotherapy to halt the free-running cycle of totally blind people, in which case there is no interaction with light exposure. Clinically, we have found melatonin especially useful for DSPS in con- junction with postsleep light therapy. Although light monotherapy can be effective for DSPS (e.g., Case 1), the advancing schedule is especially difficult for patients who are not falling asleep until early morning. Adding melato- nin 4 to 6 hours before current sleep onset and moving light exposure and melatonin ingestion gradually earlier— as an ensemble—can expedite progress. Once sleep has stabilized, melatonin might maintain the pattern after dis- continuation of light therapy, with spontaneous exposure to early morning postsleep light. The phase-advancing strategy combined three chronotherapeutic methods: 0.2 mg_ controlled- release melatonin® in the evening, blue-blocking (400 to 535 nm) glasses until sleep onset, and 1 hour of light therapy at 10,000 lux upon awakening. Melato- nin was initially taken too early (about 7 hours before sleep onset) because the patient insisted he was ready to fall asleep earlier; after stabilization, the delay to sleep was about 4 to 5 hours. He followed a 1- to 3-day schedule of 30-minute advances in wakeup time and light therapy, based on his level of confi- dence that he would not oversleep. Sleep onset remained spontaneous throughout. He achieved the goal of sleep from 11:30 PM to 7 AM in about 2 weeks and expressed incredulity that this could happen.
Patient J.M. (Fig.149-4) is male, age 28 years, and an accomplished scholar. He had experienced extreme delayed sleep phase disorder since adolescence. It was aggravated in recent years, with sleep onset around 7 AM and waking around 3 pM. The distinct downside for him was the inability to collaborate with colleagues during the normal workday. He resisted hypnotic medication but intermittently used alcohol to fall asleep a few hours earlier. Melatonin has been used as monotherapy to halt the free-running cycle of totally blind people, in which case there is no interaction with light exposure. Clinically, we have found melatonin especially useful for DSPS in con- junction with postsleep light therapy. Although light monotherapy can be effective for DSPS (e.g., Case 1), the advancing schedule is especially difficult for patients who are not falling asleep until early morning. Adding melato- nin 4 to 6 hours before current sleep onset and moving light exposure and melatonin ingestion gradually earlier— as an ensemble—can expedite progress. Once sleep has stabilized, melatonin might maintain the pattern after dis- continuation of light therapy, with spontaneous exposure to early morning postsleep light. The phase-advancing strategy combined three chronotherapeutic methods: 0.2 mg_ controlled- release melatonin® in the evening, blue-blocking (400 to 535 nm) glasses until sleep onset, and 1 hour of light therapy at 10,000 lux upon awakening. Melato- nin was initially taken too early (about 7 hours before sleep onset) because the patient insisted he was ready to fall asleep earlier; after stabilization, the delay to sleep was about 4 to 5 hours. He followed a 1- to 3-day schedule of 30-minute advances in wakeup time and light therapy, based on his level of confi- dence that he would not oversleep. Sleep onset remained spontaneous throughout. He achieved the goal of sleep from 11:30 PM to 7 AM in about 2 weeks and expressed incredulity that this could happen.
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‘(dorpiva ‘sravieddy 99s) uoNeinSyUOS doJf-1e]S & UT IYST AyisuayuT J9YSty 07 saimsodxe J91I0Ys YIM pajoa14109 aq JY.sTur syeqMeip asay_T, IOFWIOOSIP d1v]s pue suUOTSsas a1Ns -odxa suo] ay} UsAIs QuOUNeeN onUNUOD 0} pouTpap sisal -qns ysour 4y9UAq styA aydsaq] “Noy | Inoge Aq paseas19ap ssoupnyoyeM ouIMIYsIu Yuounee.n jo shep Z] Joye ‘Aouad -yjo daajs paaoidurr pomoys dnois 3YS1] WYSi1q oy], “erU -WOsuT dduvUaIUTeUT daaqs JO soLIosTY YALM s}alqns A].19pya UI [OQUOD IYSI[-por uNpP & YIM (SIMOY Z IOF XN] YOOP<) ainsodxe 3ys]-31Y4st1q Surusad Jo sjoajja oy poieduros .sonseayjoo pue yjaqdurey “urodU0d JO asned uOUTUIOD B SI ouIN ast Ayrva osoym ‘ApJopja aya Suoure quoyeaoid d1OUI SI I ‘paqejoi-ase AporNs jou st GgSy Yysnowpyy
Figure 149-5 Self-report sleep and light therapy record for Patient S.H. (winter depression), who first received a trial of evening light (5:00 pm), then morning light (6:30 Am). Green bars, sleep episodes on successive days (top to bottom); sun symbols, 15-minute intervals of 10,000-lux light exposure; D, depression at clinical evaluation; R, remission at clinical evalu- ation. Pretreatment baseline, 17 days (see Case 7 in the text).
Figure 149-5 Self-report sleep and light therapy record for Patient S.H. (winter depression), who first received a trial of evening light (5:00 pm), then morning light (6:30 Am). Green bars, sleep episodes on successive days (top to bottom); sun symbols, 15-minute intervals of 10,000-lux light exposure; D, depression at clinical evaluation; R, remission at clinical evalu- ation. Pretreatment baseline, 17 days (see Case 7 in the text).

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  5. Sf uEruol 'W unlucl_ I I '91z-!-0zr0s:I002 ,{-urrqris4 lrrg ipnrs pa11o.oro:r t :CIys Jo rururtec.u eqr ur lq5rl rqSr-rq put uonqnurrs u.lrrC Irri '\'I/t aloB '11q:cpn 'qg ii:ery 61 '6ft1zz'<l '/66t lra5rr) :1asu11 a:ru:rr.rd lnrurlc pur r{rr:rsa::rsq 3u[rr8e]ur :aruJlrs darl\^ rou)r'lrv\ zyrnqrq^:u1 daals uo rq8rl l! unural 6 '8Zr-{n (l '0661 lsserd,irrs.rl)^run pJ(lxo:riro ^r|)N srrrqriqr lt:)I8(]l0(l pue darl)^ srorpi')l rnoqpoC 'l rrsrrldtuol,! rul -(larls pu0 'uruorrl3tu 'uorsst.rdap rerull\ 'srrlnadpra{r tq8rlr.lr1. sC .ri5tlqrs '!t rtuuel 8 |(z:61i6t rrurqr,isd IorB uorueuorur )!nedr..qr s r-r;fr11.i,-,'o9,1.i jsnp fut u,\\tc B urxrF.d '.s rsrnqrrr,r rc rin-rNrs 'l{ utuueJ I 9ft-t,fi:s r:000a slLqriqd lolfl l"rqrrl iFro \u,\q) iqr iq rcs rrrrjaluuDrrtl rn:rpur -lD urunq tq.t, lrl ra') tqrn ) '\r rrDsnl-z.rr^\ l\) oluil'UECI 9 'II-t:92:066t IIn{ lorr.ur.rtqdoqr.is4 rrorssa:drp rarur^\Jo ruturrrut.ro; r-rnsodr:r lqSrl rsueNr le (l.toiJUTUJI lr re'Sc regnlrlrs'I,{ ulrturrt_ 'SI uL.rrr.rQl t '/0(-20(:6(:900a,fill {r,tsd lorg 1sO!'I) srPorD tuDrrrue-rqn-rl PU&r,{\oriru enl(l rPr,{{ rrProsrP a^|lr3JJr: |:uon:rs rq trtlr:aqr rq8rt lE ra ':) rpaurd 'fl lru g 'l) urLLDirqO , 'fta-Lta:tatz66l prosrq rrag\i Ir)rssrrclep ltuosr:os:og ldr::erp rq8q ur s!]8uile^D.'rr V rrlor^E!|rJo srl'lt. a'{.t, lxra '\/[rofrlv,y ul:trEr{]ng i\\U rup-l t '6l-ll:81:100a sroqr,(qu Iorfl I surxLrnrl ur uruonrlau Sursserd dns ur arnsrxke lrurtal iorredns uBqt o^rrJal]r aJo(r sr olnsodJ{e rqSrl lruqrr roucJ(l 'F ro 'Cl,\ JBllod 'dl urtrueH ':) ueurlrrlrJ Z €69t idPraqltq6!t . 6tt rlldvHf 'IrS tas{lddns I)6(l)l0a l:)ud Lrrrrl Irsprosrp lro,''r xrqs qrr.$ ruaorxl aqr;-rrr8rutl4 [,1ld:oqa 11
  6. ZI 60t:9t:0102 qrl'rrH uorr^u:{ Iror$ f purrs 1:o.s rq5ru.lo sDrlja a^DEiiau r$ DBrarrnn)r or sainsraw 'IE rc,l\I.{ora.8ry, .g rot;'l;::ir,,;t,;}lHr.' r|le;H rlnN I rsFsrD s,r.rur;rlzJv ur )rulxi.rusrp daalsJlr t auraSr -lrurrr rdolore(r.ruqd-uoN Ir la '1 uBrupcrrrl '[ rizrr:Z rU phr]C pt 'f6-99:ZZlbt0Z pol,t PrJJrso,t .uors -sr.rdcp ruDrarl roj [rnlr?lu lu]urrt :rnne(hraqJ, HU purla()JI .l 'Si-/Z:th I 0Z rJS relcu,turprqr,,lsd I rrt *r,ll|"r'p ::norlrisd ur (AUrB l)olr llur \Lriq! r]r rrcrpFr-) tI(I ur^()fl '!N wrlrolrcJ +l(l unr)J '!'r ruorcr.l uolllurpprM ql lru'rd Jo prcqr qndgl ( 5n\' 0t0Z /i.lrerw,isd 1or5J lorturrr:qck:qr,isck:.rncNI llo:4 uorssardap ur suourJldrur lLri!u -trJlr pur surqr,iqr utrrfrJrr') l,V {EI{'As4rrDrEI r d euo.l.luol\' el '91,1-t0t,0l1Sa,r)l sruqriqu lorg I sroprosrr) drols :q lueuuLr:r.u rq;t-r1 uo l.r<xle: rlo1 IstI r(Drpa rl! u?tlrql I 26. Zigman S. Msion enhancement using a short wavelength light- absorbing filter Optom \4s Sci 1990;67:100 104.
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