Chapter 5
Bright Light for Depression: The Scientific Evidence

Bright light treatment for winter depression has been supported by dozens of studies demonstrating beneficial results (though there have been a few studies with unsuccessful results).[55]  The Clinical Practice Guidelines issued by the U.S. Department of Health and Human Services[56]  recognized bright light as a generally accepted treatment for winter depression.

Regarding the more-common non-seasonal depression, a formal Cochrane Collaboration meta-analysis showed that bright light is effective for non-seasonal depression.[57]  Cochrane reviews are the international gold standard for evaluating the clinical evidence for various treatments. In an abstract, Tuunainen expanded this analysis. A formal American Psychiatric Association Review found that bright light was effective for SAD but questioned the value for non-seasonal depression.[58]  However, the Psychiatric Association authors later admitted that they had made an error in computing their meta-analysis, so the benefit was greater than they had concluded. A more recent French review concluded that bright light therapy was useful for nonseasonal depression, at least combined with antidepressant drugs.[59]  There have now been several independent systematic reviews concluding that light treatment is effective for nonseasonal depression.[60] 

Recent studies emphasize the usefulness of bright light in treating depressed elderly individuals in the home[61]  and in treating pregnant and postpartum women with depression.[62]  Interest has been renewed in “chronotherapeutics,” a combination of morning bright light treatment with wake therapy, sometimes combined with moving the sleep interval a bit earlier as well.[63]  As of 2019, I do not know of adequate randomized comparisons of the effectiveness of combined chronotherapy versus morning light treatment by itself, but the combined benefits of chronotherapy do appear rather encouraging.

5.A.  Is bright light only good in winter?

The earliest controlled report of bright light treatment for seasonal affective disorder (SAD) described remarkable 52% net benefits within one week; however, the bright light–treated patients were given high expectations which were not matched in the placebo-treated group.[64]  Patients with high expectations often report improvement through the power of positive thinking, but benefits of positive thinking need to be separated scientifically from the effects of bright light. Later and larger studies of SAD treatment have indicated that bright light may not be more useful than antidepressant drugs or psychotherapy.[65]  It does not afford a direct randomized comparison, but bright light for non-seasonal depression did better compared to fluoxetine than did bright light compared to fluoxetine for SAD in somewhat similar studies both carried out by Lam and colleagues.[66] 

Even if we were sure that SAD patients responded better to light than other depressed patients, it would often be hard to tell what type of depression a person suffers. Follow-up of SAD patients by Dr. Rosenthal’s research group showed that the majority of patients first defined as SAD eventually displayed summer symptoms, if their illnesses continued to recur, and many needed antidepressant drugs.[67]  Over follow-up, such patients may be perceived as nonseasonal according to accepted criteria. Many SAD patients eventually require both bright light treatment and antidepressant medications outside the winter months. Because of controversial criteria and complex clinical course, it may often be impossible to define whether a depressed patient does or does not have SAD, so restricting light therapy to SAD would not be very practical.

To summarize my opinion, even when seasonal pattern can be distinguished, there is no assurance that light treatment will work better in seasonal than in nonseasonal patients, nor does seasonality exclude the usefulness of antidepressant medication in addition to bright light. In conclusion, in my opinion, bright light is useful for people who are depressed, whether or not we think that they have SAD or winter depression. It is likely that for both nonseasonal and SAD patients, a combination of bright light and antidepressant drugs is advisable, with possible addition of wake therapy and psychotherapy.

5.B.  More perspective on antidepressant medication

To have perspective on the values of bright light treatment, it is useful to critically consider the benefits which result from antidepressant drugs. Hundreds or perhaps thousands of controlled trials of antidepressant medications have been reported, with a great preponderance of evidence that medicated patients improve somewhat faster than comparison patients given placebo. Placebo means an inactive, dummy treatment. Nevertheless, perhaps misled by pharmaceutical company marketing, many physicians suppose that the benefits of antidepressant drugs are greater than such trials actually demonstrate. The benefits were generally minor on average.

Because antidepressant medications may require six to 16 weeks to achieve substantial benefit, patients given placebo (dummy pills) for the same interval often display spontaneous remission. They get better by themselves, perhaps helped by hope and by encouragement from the researchers. The alleviation of symptoms attained during antidepressant drug treatment in most studies is due more to this spontaneous remission than to medication benefits. The benefits of antidepressant drugs are only clearly understood when the percentage remission of symptoms achieved with placebo is subtracted from the remission accompanying medication.

Only recently have overall and unbiased assessments of antidepressant drug effects become available. A compendium of antidepressant drug trials in thousands of patients reported to the U.S. Food and Drug Administration provided a general summary of antidepressant drug effects.[68]  The advantage of this report over previous compendia was the inclusion of rather unsuccessful studies which the pharmaceutical manufacturers were obliged to report to the FDA, though they may not have wished to see such results published. In these studies, the eight-week net benefit of antidepressant drugs on the Hamilton Depression Rating Scale was only 8–12% better than the result with placebo. Another analysis of some of the same data found that the placebo groups had improved 58% percent at the last measurement and the drug-treated groups had improved 69%, a drug-related benefit of only 11%.[69]  An analysis of fluoxetine results reached similar estimates, even though some of the authors were employees of the makers of Prozac.[70]  Incidentally, this meta-analysis included only seven clinical trials comparing fluoxetine to placebo, whereas we have far more studies comparing bright light to placebo in nonseasonal depression. Dr. Lam’s study comparing fluoxetine with light treatment,[71]  illustrated above, likewise had found representative antidepressant drug effects. A comprehensive meta-analysis using response criteria obtained rather similar estimates of antidepressant drug effects and also demonstrated that there has been a bias to publish more successful results and to leave less successful results unpublished.[72]  Although these meta-analyses certainly demonstrated that antidepressant drugs have significant benefits for nonseasonal depression, the size of the antidepressant net benefit after eight weeks or more (approximately 8 to 19%) certainly does not appear superior to the one-week benefit of bright light treatment (approximately 12 to 35%). Moreover, very recent analyses have argued that antidepressant benefits are most impressive with the most severe depressions (e.g., those requiring hospitalization), whereas with relatively mild depressions, the benefits may be small or absent.[73]

It is worth noting that when antidepressant drugs fail to work well, addition of lithium treatment may be helpful. Also (particularly for young women), addition of thyroid hormone (T3 or triiodothyronine) may be helpful.

Although Dr. Lam’s studies did supply direct randomizing comparisons of bright light treatment approaches versus fluoxetine (a popular antidepressant, e.g., Prozac brand), most of the antidepressant drugs have not been directly contrasted with bright light, and the comparison trials have not been large enough and long enough to gain adequate perspective on the long-term benefits and risks. Although the benefits of bright light might be greater and are almost certainly more rapid than benefits of medication, much more is known about the long-term benefits of antidepressant drug treatment, which has been much more extensively studied when all drug studies are included. Moreover, there really is no reason to inquire whether one treatment of depression is better than the other. The important point is that bright light and antidepressant drugs are best used in combination, probably also combining at least a half-night of wake therapy and perhaps psychotherapy as well.

5.C.  Be careful of dangerous new treatments for depression

In 2019, we have recently been reading considerable publicity about allegedly superior benefits for depression using implanted vagus-nerve stimulators or ketamine-related drug infusions. There has not yet been that much published about these new treatments, which have not been adequately studied. So far as I can understand, implanted vagus stimulators and ketamine infusions might be less effective than bright light treatments, probably far more dangerous, vastly more painful and inconvenient, and vastly more expensive. I have not seen evidence that these new treatments work more rapidly. The greater cost may be potentially profitable for some proponents advocating these two novel treatments, but I do not understand claims that the greater expense will help the patients more than bright light. Another kind of desperation treatment is deep brain electrical stimulation or lesioning.[74]  I have not seen adequate evidence for these deep brain treatments, but decades of history of brain-lesioning treatments make me very suspicious of the safety of deep brain neurophysiologic approaches.

Remember, bright light treatment of depression has been tested in controlled-trials since 1981 and had previously been tried informally virtually throughout recorded history. There have now been dozens of randomized controlled trials published. Probably more than one million patients have tried modern bright light treatments for depression. Safety has been studied systematically, showing that serious risks of bright light treatment are evidently extremely rare. It would be misguided for a patient to try treatments that are obviously more risky without controlled trials evidence that the implantation or intravenous treatments give better results than bright light.

Endnotes for Chapter 5

55. Canadian Consensus Guidelines for the Treatment of Seasonal Affective Disorder. Clinical and Academic Publishing, Vancouver, 1999. Lam, R.W. and Tam, E.M. A Clinician’s Guide to Using Light Therapy. New York, Cambridge University Press, 2009. [return]

56. Depression Guideline Panel. Depression in Primary Care: Volume 2. Treatment of Major Depression.  Clinical Practice Guideline Number 5.1, U.S. Dept. HHS, AHCPR Publication 93-0551, 1993. [return]

57. Tuunainen A, Kripke DF, Endo T. Light therapy for non-seasonal depression. Cochrane Database Syst Rev. 2004Link to a website outside this ebook;(2):CD004050. [return]

58. Golden RN, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am.J Psychiatry 162(4)Link to a website outside this ebook, 656-662. 2005. [return]

59. Even C, Schröder CM, Friedman S, and Rouillon F. The efficacy of light therapy in nonseasonal depression: A systematic review. J Affect.Disord. 108, 11-23. 2008. [return]

60. Chang CH, Liu CY, Chen SJ, Tsai HC.  Efficacy of light therapy on nonseasonal depression among elderly adults: a systematic review and meta-analysis [Corrigendum]  Neuropsychiatr Dis Treat 2016Link to a website outside this ebook; 26(6):1037-47; Perera S, Eisen R, Bhatt M, et al. Light therapy for non-seasonal depression: systematic review and meta-analysis.  Eur Neuropsychopharmacol 2016Link to a website outside this ebook;2(2):116-26; Tseng PT, Chen YW, Tu KY, et al. Light therapy in the treatment of patients with bipolar depression: A meta-analytic study.  Eur Neuropsychopharmacol 2016;26(6):1037-47; Zhao X, Ma J, Wu S, Chi I, Bai Z. Light therapy for older patients with non-seasonal depression: A systematic review and meta-analysis.  J Affect Disord 2018;232:291-9.[return]

61. Lieverse R, van Someren EJ, Nielen MM, Uitdehaag, BM, Smit, JH, and Hoogendijk, WJ. Bright light treatment in elderly patients with nonseasonal major depressive disorder: a randomized placebo-controlled trial. Arch Gen.Psychiatry 68(1)Link to a website outside this ebook, 61-70. 2011. [return]

62. Wirz-Justice A, Bader A, Frisch U, Stieglitz RD, Alder J, Bitzer J, Hosli I, Jazbec S, Benedetti F, Terman M, Wisner KL, and Riecher-Rossler A. A randomized, double-blind, placebo-controlled study of light therapy for antepartum depression. J Clin Psychiatry. 72:986-993, 2011. [return]

63. Wirz-Justice, A., Benedetti, F., and Terman, M. Chronotherapeutics for Affective Disorders: A clinician’s manual for light and wake therapy. 1-116. 2009. Basel, Karger. A second, revised edition of this manual was published in June 2013, ISBN 978-3-318-02090-8, and can be ordered through Karger Medical and Scientific Publishers, to a website outside this ebook; Wu JC, Kelsoe JR, Schachat C, et al. Rapid and sustained antidepressant response with sleep deprivation and chronotherapy in bipolar disorder. Biol Psychiatry 2009;66(3):298-301.[return]

64. Rosenthal, NE et al.  Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy.  Arch.Gen.Psychiatry.1984;41:72-80. [return]

65. Meyerhoff J, Young MA, Rohan KJ. Patterns of depressive symptom remission during the treatment of seasonal affective disorder with cognitive-behavioral therapy or light therapy. Depress AnxietyLink to a website outside this ebook2018;35(5):457-67; Lam RW, Levitt AJ, Levitan RD, et al. 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 2006;163(5):805-12[return]

66. Lam RW, Levitt AJ, Levitan RD, et al. Efficacy of Bright Light Treatment, Fluoxetine, and the Combination in Patients With Nonseasonal Major Depressive Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2016;Link to a website outside this ebook 73(1):56-63; Lam RW, Levitt AJ, Levitan RD, et al. 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 2006;163(5):805-12[return]

67. Schwartz, PJ et al.  Winter seasonal affective disorder:  A follow-up study of the first 59 patients of the National Institute of Mental Health Seasonal Studies Program.  Am.J.Psychiatry. 1996; 153:1028-1036. [return]

68. Khan, A et al.  Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials.  Arch Gen Psychiatry. 2000;57:311-328. [return]

69. Storosum JG, Elferink AJ, van Zwieten BJ, van den Brink W, Gersons BP, van Strik R, Broekmans AW.  Short-term efficacy of tricyclic antidepressants revisited:  A meta-analytic study. Eur Neuropsychopharmacol. 2001 Apr;11(2):173-80. [return]

70. Bech, P et al.  Meta-analysis of randomised controlled trials of fluoxetine v. placebo and tricyclic antidepressants in the short-term treatment of major depression.  Brit.J.Psychiat. 2000Link to a website outside this ebook;176:421-428. [return]

71. Lam RW, Levitt AJ, Levitan RD, et al. Efficacy of Bright Light Treatment, Fluoxetine, and the Combination in Patients With Nonseasonal Major Depressive Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2016;Link to a website outside this ebook 73(1):56-63. [return]

72. Mulrow, CD et al.  Treatment of Depression:  Newer Pharmacotherapies. USPHS AHCPR, Rockville, MD, 1999.   Evidence Report/Technology Assessment No. 7Link to a website outside this ebook.  AHCPR Publication No. 99-E014:1-2-32.[return]

73. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, and Fawcett J. Antidepressant drug effects and depression severity: a patient-level meta-analysis. Journal of the American Medical Association 303(1)Link to a website outside this ebook, 47-53, 2010. [return]

74. Kisely S, Li A, Warren N, Siskind D. A systematic review and meta-analysis of deep brain stimulation for depression. Depress Anxiety 2018Link to a website outside this ebook;35(5):468-80. [return]