Light therapy for seasonal depressive disorder
Dr. Andrés Heerlein

 

Introduction
Since the work of Rosenthal and colleagues1 pioneers of seasonal affective disorder (SAD) and phototherapy, many authors have stressed the need to include this kind of therapeutic tool in the treatment guidelines disorders ánimo.1-3 Light therapy was first introduced for the specific treatment of SAD, but has since shown some effectiveness in a number of conditions associated with mood disorders, such as, for example, depression during pregnancy, puerperal disorders, major depression and lower, dysthymia, bipolar depression and others.4 In recent decades has significantly increased the use of phototherapy in secondary and tertiary care, but also favorable results in health care primaria.5 Its use has not been restricted to the field of mood disorders, but also has been tested in the eating disorder in psycho-oncology and psicogeriatría, particularly in the treatment of asylum patients. On another level, phototherapy has demonstrated a potentiating effect interesting traditional antidepressant therapies, as well as a significant prophylactic effect, especially for patients with SAD.
However, in the field of major depressive disorders light therapy remains a technical some demanded by specialists and patients. This may spread to poor received or the difficulty in identifying and achieving more clearly define the subgroup diagnosis with high sensitivity to this therapeutic strategy due. While there have made ​​psychopathological, psychometric and personality traits that predict sensitivity to light therapy studies, the results have not been entirely temporal plane concluyentes.6 In some claim that seasonal depressions starting in fall or winter would fotoestimulante.1 the most susceptible to this effect is based on the relationship between latitude, depressivity and suicidality. Numerous studies about SAD have shown that the seasonal effect is associated with important latitudinal differences in photoperiod. This was observed in a study conducted in Norway, in extreme northern latitude of 70 degrees, recorded a high incidence of SAD in winter. In Denmark TAE higher frequencies were also recorded in that period. However, the relationship between
photoperiod and the APR has not been definitively confirmed. A study by Murray, 2 in Australia, failed to demonstrate a certain relationship between SAD and winter photoperiod variations. Regarding the efficacy of phototherapy in SAD, we should also mention that the studies found superior efficacy to placebo.
We see that there is not yet a fully proven and a clear diagnostic definition subgroup of depressed patients who respond best to the phototherapy. Here we present the case of a patient with major depressive disorder (MDD) without awareness of having a seasonal pattern, who successfully respond to treatment with phototherapy alone.
Case
RN Patient, 39, married, wife of medical, professional and owner House, 3 children 13, 12 and 7 years.
Reason for consultation
depressivity, emotional lability and incontinence, cognitive and autonomic symptoms, sleep-wake and progressive anhedonia, several weeks of evolution cycle. Consultation spontaneously.
Anamnesis next
No previous history, often referred to be a very dynamic, active and positive person. . Weeks before the consultation would have been loss of momentum and interest in its activities, disappointment, hyperphagia and hypersomnia, anhedonia and emotional lability
The patient says: “For years I had been noticing that my mood waned in winter and the desire to make things disappear . Increased sleep, I felt almost like a bear preparing for hibernation. Why say that he was weeping. My decay, according to my assessment, coincided with several factors: a daughter with cerebral palsy, the stress of raising well two other school-age daughters and all that entails preadolescence, lack of meaningful employment, the significant increase in my body weight, and on the other hand, endogenous depression of my father, who had surely inherited something. ”
Ananmesis remote
pregnancy without known disorders, normal delivery, without a history of fetal distress or postpartum complications. Normal psychomotor development. . No significant medical or surgical history
Habits:
Snuff: (-)
Alcohol: occasionally, moderate social drinking.
Drugs: (-)
Psychosocial: a daughter with cerebral palsy, lack of current occupation.
Family history: father with several episodes . endogenous depressive
physical and neurological exam
normotensive, afebrile, heart rate 92 per minute, sinus rhythm. Isochoric, reactive pupils. Cranial nerves were normal. Strength and muscle tone maintained. Segmental examination without pathological findings. Laboratory tests: blood count, biochemical profile, TSH and normal urine Complete.
mental examination on admission
lucid and oriented in time, space, situations and about people. Cognitive functions within normal limits. The formal course of thought has ruminations and slowing. Refer a diffuse anxiety, daytime dominance. The contents of thought does not reveal the presence of delusions. The perception is preserved. The mood is shown depressed, with marked emotional lability. Circadian rhythms are altered, with hypersomnia and hyperorexia. There are social withdrawal without ideas or death wishes. The test in Hamilton depression scale (HAM-D17) at admission is 26 points.
premorbid personality
Extrovert, orderly, stable, moderate neuroticism.
Income Diagnosis
Axis I: major depressive disorder with seasonal pattern
Axis II. without disorder
Axis III: Healthy
Axis IV: (-)
Axis V: GAF: 80%
Treatment and evolution
During the first interview is evident the seasonal pattern of your disorder. The patient finds mild or moderate depressive episodes earlier, occurred during the previous winters, with a clear spontaneous improvement in the summer. It also recognizes cognitive and autonomic changes during the winter period. . These findings promote an indication of an exclusive, morning, with exposure of about 5,000 lux for 50 minutes a day, which begins in the next few days phototherapy
The patient reports: “In the first consultation where the psychiatrist I told him [the above factors above] and had the clear perception of a cyclical situation as intensely enjoyed my summer vacation. The psychiatrist immediately associated with the lack of light and recommended phototherapy, before trying an antidepressant. The result was surprising. After 3 days, it was gone hypersomnia. After a week was a remarkable change of mind and improved self-esteem, which lowered my anxiety about food. For example: after months without taking decisions, I consulted by the lamp for phototherapy, l bought
to have installed in my home. Every day I’m exposed to 10,000 lux 30 minutes and I think it changed my life. ”
Within 10 days of starting treatment the patient presented a HAM-D17 Test 4 points, which was interpreted as a complete remission. There has been no relapse or recurrence in the last year.
Discussion
Since the original descriptions of Rosenthal1 many authors have highlighted the advantages of supplementing the treatment of SAD phototherapy. In numerous studies, phototherapy has proven more effective than placebo and as effective as some treatments with selective reuptake inhibitors (SSRIs). Likewise, phototherapy has revealed potentiating the antidepressant response to different drugs, not only in the TAE but non-seasonal major depression. Finally we mentioned the other applications described for phototherapy, inside and outside the field of mood disorders.
This case is novel for different reasons. We observe the typical story of a patient with recurrent depression, which after suffering several episodes untreated finally decide to consult a specialist. This would normally have tended to choose the drug-psychotherapeutic way to start treatment, but the presence of some “atypical” symptoms such as hypersomnia and hyperphagia took him to see more detail about a seasonal pattern. Only so it was possible to apply the diagnostic hypothesis of SAD, suggesting to start treatment with phototherapy as a sole therapy. Unlike other studies, our patient reported no adverse effects during terapia.7
A second interesting aspect of this case is the rapid response to phototherapy. Most studies report favorable responses in 2 to 3 weeks of treatment. In this case favorably within 4 days of treatment response was observed. Complete remission occurred at the eighth session. This response has continued until today because of a prophylactic phototherapy domestic control.
Several studies suggest that hyperphagia Chronobiological would be a type of mood disorder indepensiente sync, and would not respond to fototerapia.8 This case clearly shows that the response, sometimes, if it is closely linked to the disappearance of hyperphagia, as described by the patient. Something similar happens with the timing of hypersomnia.
With regard to the aspects of personality, we want to emphasize that these are also useful in the time of applying a diagnosis of SAD. Some studies have revealed differences in the premorbid personality of patients with SAD when compared to other patients with SAD grupos.6 reveal higher levels of extraversion and lower neuroticism, when compared, for example, bipolar depression. This case confirms these findings, suggesting that an adequate examination of premorbid personality traits can provide greater support to the diagnostic hypothesis, favoring clinical work and therapeutic success.
In short, we can say that light therapy is an effective therapeutic tool cost moderate, low complexity and low side effect profile. Its use, exclusively or combined with other antidepressant strategies, enriches the armamentarium of clinical and increases the chances of giving an efficient and effective service in a wide range of psychiatric disorders. However, it is clear that the therapy is not always effective, yet to know the characteristics that predict a good response and has a side effect profile considerar.7 future clinical studies considering psychopathological aspects, and personality chronobiologic They should shed further light on its proper use in the psychiatric clinic.
Bibliography
1. Rosenthal NE, Sack DA, Gillin JC, et al. Seasonal affective disorder. A description of
the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry. 1984 Jan; 41: 72-80.
2. Levitt AJ, Lam RW, Levitan R. A comparison of open treatment of seasonal major and minor depression with light therapy. J Affect Disord. 2002 Sep; 71: 243-248.
3. Eastman CI, Young MA, Fogg LF, Liu L, Meaden PM. Bright light treatment of winter depression: a placebo-controlled trial. Arch Gen Psychiatry. 1998 Oct; 55: 883-889.
4. Oren DA, Wisner KL, Spinelli M, et al. An open trial of morning light therapy for treatment of antepartum depression. Am J Psychiatry. 2002; 159: 666-669.
5. Wileman SM, Eagles JM, Andrew JE, et al. Light therapy for seasonal affective disorder in primary care: randomized controlled trial. Br J Psychiatry. 2001; 178: 311-316.
June. Jain U, MA Blais, Otto MW, Hirshfeld DR, Sachs GS. Five-factor personality traits in patients With seasonal depression: treatment effects and comparisons With bipolar patients. J Affect Disord. 1999; 55: 51-54.
7. Terman M, Terman JS. Bright light therapy: side effects and benefits across the spectrum symptom. J Clin Psychiatry. 1999; 60: 799-808.
8. Cugini P, Passynkova NR, Di Cristofano F, et al. Daily sensation of hunger, before and after phototherapy, in subjects with depression-type seasonal affective disorder. Clin Ter. 2001; 152: 353-362.