University of Groningen
Can winter depression be prevented by light treatment?
Meesters, Ybe; Lambers, Petrus A.; Jansen, Jacob; Bouhuys, Antoinette L.; Beersma,
Domien G.M.; Hoofdakker, Rutger H. van den
Published in:
Journal of Affective Disorders
DOI:
10.1016/0165-0327(91)90094-9
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1991
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Meesters, Y., Lambers, P. A., Jansen, J., Bouhuys, A. L., Beersma, D. G. M., & Hoofdakker, R. H. V. D.
(1991). Can winter depression be prevented by light treatment? Journal of Affective Disorders, 23(2), 7579. https://doi.org/10.1016/0165-0327(91)90094-9
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Journal
ofiiffectkle
0 1991 Elsevier
ADONIS
Disorders,
Science
zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
23 (1991) 75-79
Publishers
75
B.V. All rights reserved 0165-0327/91/$03.50
016503279100123P
JAD 00836
Can winter depression be prevented by light treatment?
Ybe Meesters, Petrus A. Lambers, Jaap H.C. Jansen, Antoinette
L. Bouhuys,
Domien G.M. Beersma and Rutger H. van den Hoofdakker
Department
of Biological
Psychiatry,
University
of Groningen,
The Netherlands
(Received 31 December
1990)
(Revision received 11 June 1991)
(Accepted 22 July 1991)
Summary
The administration
of light at the development
of the first signs of a winter depression
appears to
prevent it from developing into a full-blown depression.
No patient from a group of 10 treated in this way
developed any signs of depression
during the rest of the winter season, while five of seven patients from
a control group became depressed and needed treatment
during the winter season.
Key words:
Seasonal
affective
disorder;
Prevention;
Introduction
Seasonal affective disorder (SAD), winter type,
is a depressive
syndrome
characterized
by the
occurrence
of depression
each autumn and winter, followed by complete recovery in spring and
summer (Rosenthal
et al., 1984). Hypersomnia,
increased
appetite and weight gain are frequent
concomitants.
The prevalence
of SAD is estimated to be 4.3-10% (Kasper et al., 1989). It has
been hypothesized
that the syndrome is caused by
the seasonal fluctuation
in light intensity. Various
studies have shown that light therapy is a very
effective form of treatment
for SAD (Terman et
Address
for correspondence:
Ybe Meesters,
Psychiatric
Clinic, University
of Groningen,
Department
of Biological
Psychiatry, Oostersingel
59, 9713 EZ Groningen,
The Netherlands.
Depression;
Light therapy
al., 1989). Not all patients who suffer from SAD
become depressed every winter (Rosenthal
et al.,
1984). Without prophylaxis
or treatment,
in one
study 67% of the SAD subjects diagnosed in the
summer became depressed
in the following winter, while 33% did not (Thompson,
1989).
This report concerns an ongoing study, in which
we examine whether light treatment
can stop the
development
of a winter depressive episode at a
very early stage. For that purpose we compare
the course of mood in a group of winter depressives who receive light therapy at the appearance
of the first signs of a depression
with that in a
control group of patients
who do not receive
therapy.
Methods
All participants
met the criteria
for winter
depression as described by Rosenthal et al. (1984).
76
From September
1989 until the beginning of April
1990, the subjects’ mood was assessed at weekly
intervals, by means of self-ratings
on the Adjective Mood Scale CAMS) Won Zerssen, 1986) and
the Beck Depression
Inventory
(BDI) (Beck et
al., 1961). The first occurrence
of a BDI score 2
13 was considered
to represent
the first sign of a
winter depression.
The value of 13 was derived
on the basis of the following reasoning.
According to Beck et al. (1961) the cut-off between mild
depression
and no depression
is at a BDI score of
17. Taking into account that most SAD people
will not score on the sleep, eating and weight
items, a score of 13 seems reasonable
as a criterion for a very mild (beginning)
winter depression. For the same reason a score of 22 is chosen
as the cut-off point for severe depression
for
SAD subjects in this study. It corresponds
to the
value of 26 taken by Beck et al. as the lower limit
value for severe depression.
Patients who reached
a BDI score & 13 were randomly
assigned to either the treatment
or the control group. For each
group the numbers of patients who were selected
in each month of the winter season are indicated
in Fig. I. During the subsequent
period of 24
days, patients in both groups completed the AMS
three times a day, and the BDI once a week.
After a 4-day baseline
period (called ‘before’),
light therapy was given during a period of 5
consecutive
days, from 9.00 to 12.00 a.m. (this
period is called ‘during’). The light came from a
set of four full-spectrum
fluorescent
light tubes
(Philips TL 58w/85, 2500 Lux). Mood measurements were continued
during withdrawal.
This
latter period was split into a lo-day period (‘after
I’), and a subsequent
5-day period (‘after II’). At
the end of the ‘after I’ interval, mood was rated
by means of the 21-item Hamilton
Rating Scale
for Depression
(HRSD) (Hamilton,
1967). Interviewers were members
of the research
team.
These four intervals taken together constitute
the
‘experimental
period’. The subsequent
part of the
winter season is denoted the ‘follow-up period’.
Here mood was assessed weekly (BDI). Patients
in the control group who reached a BDI score 2
22 during the experimental
period were considered depressed
and were therefore
offered light
treatment.
Once they received treatment,
these
patients could no longer serve as controls in the
present study.
Thirty-five
patients
were
monitored
from
September
onward, 10 men, 25 women. Twenty-
8
1
nov
de c
ja n
fe b
month
Fig. 1. Cumulative
number of subjects who became depressed (BDI > 13) during the season. H control group, ~4 subjects of the
control group who became severely depressed (BDI 2 22), W treatment
group. In the treatment
group no patient developed signs
of depression during the remaining part of the winter season. In this figure, the 2 drop-outs are not included.
77
two came from a group of patients that had taken
part in a previous study (Richter et al., 19911, the
remaining
13 were recruited through media publicity during the course of the study. All patients
had BDI scores below 13 at the beginning of the
study.
Nineteen of the original 35 subjects obtained a
BDI score > 13 and were therefore considered to
be developing
a depression.
Their mean age was
39 ( f 10 SD). Ten of them were given preventive
light treatment
(two men, eight women>, the others constituted
the control group (three men, six
women) (Fig. 1). The two groups did not differ in
severity of depression
during the baseline period.
Within the experimental
period of 24 days three
patients
from the control
group dropped
out.
One patient became severely depressed
(BDI k
22) and had to be treated with light. Two other
patients dropped out because of the unpleasant
obligation to perform the frequent mood ratings.
Patients visited the clinic for light treatment
and
HRSD
interviews.
They filled out self-rating
scales at home.
TABLE
1
THE AVERAGE
EXPERIMENTAL
COURSE
PERIOD
OF
Treatment
AMS
Before
During
After I
After II
day 5
day 12
day 19
day 26
BDI
MOOD
group
DURING
Control
THE
group
N
Mean
SD
N
Mean
SD
10
10
10
10
10
10
10
9
28.34
19.21
15.31
13.58
15.75
7.40
6.60
5.50
11.41
11.74
12.69
9.87
6.51
5.34
6.02
4.05
9
9
9
6
9
8
7
6
21.54
19.44
23.79
28.18
12.00
13.11
15.21
19.75
12.31
8.36
11.33
9.62
9
7.21
6.22
8.97
Before = days 1-5, during
after II = days 19-24.
= days
5-9,
after
I = days
9-19,
patients
in the treatment
group failed to complete the BDI on day 26.
MANOVA with repeated measures applied to
the BDI scores during the control and treatment
periods showed a significant
interaction
effect
between time and group (F(3,39) = 12.069, P =
0.001). Furthermore,
significant improvement
was
observed in the subjects of the treatment
group
Results zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
(F(3,24) = 9.49, P = 0.00). The subjects from the
control group showed a significant worsening
of
Experimental period
the scores (F(3,15) = 4.5, P = 0.02).
Further analysis of the BDI scores of the treatment group showed that the improvement
was
BDI
immediate
(day 12 compared to day 5: F(1,13) =
The mean BDI scores of both groups are shown
8.944, P = 0.010; day 19 compared
to day 5:
in Table 1 and Fig 2. Unfortunately,
one of the 10
w
1
2
3
4
5
follow up period
6
7
8
9
10
12
14
16
18
20
22
24
weeks
Fig. 2. The course of mood
l, n = 10). Numbers
24-day experimental
period.
(.-
(Beck Depression
Inventory)
in the control group (*- - -0,
n = 9) and the treatment
group
of individuals
contributing
to the data are indicated.
Data are synchronized
with respect to the
Base = baseline period; exp = experimental
period; light = light treatment
for the treatment group.
78
F(1,13) = 9.379, P = 0.009; day 26 compared
to
between the two groups. In contrast, none of the
day 5: F(1,13) = 10.243, P = 0.007). In the control
subjects in the treatment
group became severely
group mood worsened in a more gradual way (day
depressed.
Using a chi-square test this difference
12 compared to day 5: F(1,13) = 0.801, P = 0.399;
was significant (x” = 5.4, zyxwvutsrqponmlkjihgfedcbaZYXW
df = 1, P = 0.02). Three
day 19 compared
to day 5: F(1,13) = 3.373, P =
of the severely depressed
patients in the control
0.086; day 26 compared to day 5: F(1,13) = 8.436,
group recovered after one series of 5 days of light
P = 0.012). zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
treatment,
one needed two series and one did not
AM S
The AMS scores showed a development
similar to that of the BDI scores (Table I). It should
be remarked,
though, that the mean AMS score
is based on self-ratings
which were done three
times daily, while the BDI was only completed
once a week. A significant
interaction
effect was
noted between time and group (F(3,42) = 14.571,
P = 0.001).
Again a significant improvement
of mood was
found in the treatment
group (F(3,27) = 13.81,
P = 0.00). Here too, further analysis showed an
immediate
effect of treatment
(‘during’ versus
‘before’: F(1,141= 13.585, P = 0.003; ‘after I’ versus ‘before’:
F(1,14) = 18.104, P = 0.001; ‘after
II’ versus ‘before’: F(1,14) = 34.055, P = 0.001).
Similarly, a significant deterioration
of mood was
found in the control group (F(3,15) = 7.03, P =
0.00). Also in the self-ratings
the worsening
occurred more gradually
(‘during’ versus ‘before’:
F(1,14) = 0.139, P = 0.713; ‘after I’ versus ‘before’: F(1,14) = 0.483, P = 0.505; ‘after II’ versus
‘before’: F(1,14) = 6.871, P = 0.019).
HRSD
The mean HRSD score of the treatment
group
on day 19 (in week 6) was 7.6 (f4.3
SD>, the
score of the control group was 13.2 ( f 4.9 SD).
The difference
is significant
(Mann-Whitney
U:
15.50, Z = - 2.2, P = 0.03).
Follow-up period
During the follow-up period, which lasted until
the beginning
of April, four patients of the control group became severely depressed (BDI > 22)
and therefore
received light therapy. In addition,
one control subject obtained
a BDI score 2 22
during the experimental
period. Because of therapeutic intervention
the data of these five patients no longer contributed
to the comparison
recover in response to light.
The drop-out
is reflected
by the decreasing
number
of patients
contributing
to the upper
curve in Fig. 2. In addition, Fig. 2 shows that the
number of patients in the treatment
group also
decreased
as time progressed
(lower curve). This
reduction
is not, however, due to a worsening of
mood. Here measurements
were stopped because
the end of the experiment
was set at the beginning of April. In the treatment
group not a single
patient ever exceeded the BDI value of 13. In
addition,
none of the four successfully
treated
subjects who dropped out from the control group
became depressed
again during the same winter
season.
Discussion
The administration
of light at the very first
sign of a winter depression
in this study prevented it from developing
into a full-blown
depressive episode. The treatment
even improved
mood. In contrast, the control group of patients,
who had not been given any therapy, showed a
marked deterioration
of mood. This is illustrated
by all mood variables examined. The BDI scores
suggest that the beneficial
effects of light treatment were maintained
until spring. These findings differ from the commonly
reported
relapse
period of 3-4 days (Terman
et al., 1989) and
show some similarity to the findings of Yerevanian et al. (1986), who found almost no relapse
during 14 days following successful photo treatment. In a case study Wirz-Justice
et al. (1986)
described
a patient who had no relapse up to a
few months
after treatment.
Lasting remission
was also noted for the four successfully
treated
subjects from the control group, who received
light treatment
after a BDI score 2 22 had been
reached. We do not have an explanation
for the
differences
between
the studies.
Perhaps
the
weekly contact of the subjects with the research
79
center (through
sending self-rating
scales) contributed to the lasting remission.
In interpreting
these data, the following point
has to be taken into account.
The treatment
condition
not only implied the administration
of
light, but also a visit to the clinic on 5 consecutive
mornings. In contrast, the control patients had to
carry on with their normal daily routines. Consequently, the conditions
in the two groups differ at
least in these two respects. Without proper control for these differences,
it remains uncertain
which factors are responsible
for the beneficial
effect of the treatment
condition.
Nevertheless,
even if the visits to the clinic did substantially
contribute
to the results, they are clinically and
theoretically
of sufficient interest to warrant further investigation.
References
Beck, A.T., Ward, C.H., Mendelson,
T.E., Mock, J.E. and
Erbaugh. J.K. (1961) An inventory for measuring
depression. Arch. Gen. Psychiatry 4, 561-571.
Hamilton,
M. (1967) Development
of a rating scale for primary depressive
illness. Br. J. Sot. Clin. Psychol. 6, 278296.
Kasper, S., Wehr. T.A., Bartko, J.J.. Gaist, P.A. and Rosenthal, N.E. (1989) Epidemiological
findings of seasonal
changes in mood and behavior.
A telephone
survey of
Montgomery
County, Maryland. Arch. Gen. Psychiatry 46,
823-833.
Richter,
P., Bouhuys,
A.L., Van Den Hoofdakker,
R.H.,
Beersma,
D.G.M.,
Jansen,
J.H.C.,
Lambers,
P.A.,
Meesters, Y., Jenner, J.A., Van Houwelingen,
C.A.J. and
Bos, P. (1991) The application
of imaginary light in winter
depressives compared to real light treatment.
Submitted.
Rosenthal,
N.E., Sack, D.A., Gillin, J.C., Lewy, A.J., Goodwin, F.K., Davenport,
Y., Mueller, P.S., Newsome, D.A.
and Wehr, T.A. (1984) Seasonal
affective
disorder.
A
description
of the syndrome and preliminary
findings with
light therapy. Arch. Gen. Psychiatry 41, 72-80.
Terman,
M., Terman,
J.S., Quitkin,
F.M., McGrath,
P.J.,
Stewart, J.W. and Rafferty,
B. (1989) Light therapy for
seasonal
affective disorder.
A review of efficacy. Neuropsychopharmacology
2, l-22.
Thompson,
C. (1989) The syndrome
of seasonal
affective
disorder. In: C. Thompson
and T. Silverstone (Eds.), Seasonal Affective Disorder. CNS, London, pp. 37-57.
Von Zerssen, D. (1986) Clinical self-rating
scales of the Munich Psychiatric Information
System. In: N. Sartorius and
T.A. Ban (Eds.), Assessment
of Depression.
Springer Verlag, Berlin, pp. 270-303.
Wirz-Justice.
A., Bucheli, C., Schmid, A.C. and Graw. P.
(1986) A dose relationship
in bright white treatment
of
seasonal depression.
Am. J. Psychiatry 143, 932-933.
Yerevanian,
B.I., Anderson,
J.L., Grota, L.J. and Bray, M.
(1986) Effects of bright incandescent
light on seasonal and
nonseasonal
major depressive disorder. Psychiatry Res. 18,
355-364.