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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M356-M360 (2001)
© 2001 The Gerontological Society of America

Bright Light Treatment Decreases Depression in Institutionalized Older Adults

A Placebo-Controlled Crossover Study

Isabel C. Sumayaa, Beth M. Rienzib, Jess F. Deegan, IIb and Donald E. Mossa

a Laboratory of Psychobiochemistry, University of Texas at El Paso
b Department of Psychology, California State University, Bakersfield

Isabel C. Sumaya, Department of Psychology, Psychobiochemistry Laboratory, University of Texas at El Paso, El Paso, TX, 79968-0059 E-mail: icsumaya{at}utep.edu.

Decision Editor: John E. Morley, MB, BCh


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. An important parallel exists between patients with seasonal affective disorder and institutionalized older adults. Many older patients, as a result of global physical decline and immobility, are confined to their rooms, experiencing little natural sunlight. Thus, institutionalized older adults are at risk for chronic light deprivation. Testing the hypothesis that chronic light deprivation might be responsible, at least in part, for some depression among institutionalized older adults, the aim of this study was to investigate the efficacy of morning bright light treatment on depression among older adults residing in a long-term care facility.

Methods. In a placebo controlled, crossover design, participants (N = 10, six women and four men; M age = 83.8) received each of the following: (i) 1 week (5 days) of 10,000 lux (therapeutic dose); (ii) 1 week (5 days) of 300 lux (placebo); or 1 week of no treatment (control). Each week of light treatment was 5 consecutive days, 30 minutes daily, with a wash-out period consisting of 1 week between conditions.

Results. Geriatric Depression Scale (GDS) scores at baseline during all treatment conditions were positively correlated (r = .81, p < .01) with months of institutionalization, where participants with higher GDS scores experienced more time institutionalized. Scores on the GDS remained unchanged during the placebo and control conditions, but depression scores decreased significantly during the 10,000 lux treatment (pretest GDS M = 15 vs posttest GDS M = 11, p < .01). After the 10,000 lux treatment, 50% of the participants no longer scored in the depressed range. Improvement during the 10,000 lux condition was positively correlated (r = .62, p < .05) to baseline GDS scores, where participants with higher GDS scores experienced greater improvement following the 10,000 lux treatment.

Conclusions. The results of the present study suggest that bright light treatment may be effective among institutionalized older adults, providing nonpharmacological intervention in the treatment of depression. Furthermore, the length of institutionalization may play an important role in determining the efficacy of bright light treatment for older adults in the nursing-home setting.

AS a result of global losses incurred during the third and fourth quarters of life, depression is the most prevalent psychiatric disorder among older adults. Institutionalized older adults are at further risk of episodes of depression, as they constitute the most debilitated subgroup in the aging population. Although depression is often accepted as a normal symptom of aging, despite its prevalence, depression is neither normal nor inconsequential. Depression among older adults has consistently been found to be a significant risk factor contributing to death (1)(2)(3)(4). For the institutionalized older adult, depression increases the likelihood of death by nearly 60% in the first year after onset (2)(5), leading to a possible premature death if not treated effectively. Further, in the psychosocial domain, it has been well established that depression among institutionalized older adults contributes negatively to quality of life as measured by feelings of hopelessness (6), anxiety (7), and self-esteem (8).

Accepted as the standard mode of therapy in the treatment of depression, antidepressants have a proven efficacy in the general population as well as among older adults. However, given the high occurrence of polypharmacy and age-related changes in pharmacokinetics, the efficacy of drug therapy among older adults remains tenuous. In seeking a nonpharmacological intervention, the aim of this study was to introduce a nontraditional therapy—bright light administration—for the treatment of depression among institutionalized older adults.

Investigations of the efficacy of bright light treatment have focused primarily on seasonal affective disorder (SAD) for depression. SAD is characterized by recurring episodes of depression during the fall and winter months. Depressive episodes are thought to occur as the result of light deficiencies' negatively affecting brain chemistry and circadian rhythms. In fact, bright light treatment has been shown to entrain circadian rhythms and improve sleep (9)(10)(11)(12)(13)(14). Similarly, SAD patients have consistently experienced antidepressant effects from bright light treatment (15)(16)(17)(18)(19).

Although there are other important factors contributing to depression (e.g., deteriorating health, extended bereavement, loss of autonomy) among institutionalized older adults, an important parallel exits between SAD patients and institutionalized older adults. Many older patients, as a result of global physical decline and immobility, are confined to their rooms, experiencing little natural sunlight. Thus, institutionalized older adults are at risk for chronic light deprivation. The institutionalized older adults' situation creates an even more disturbing picture than SAD, as light deprivation can become a year-round condition.

Few studies have explored the hypothesis that light deprivation may be responsible, at least in part, for some depression among older adults, and even less data are available on institutionalized populations. Webb and Jarrett (20) were the first to study the efficacy of bright light treatment in older adults when they reported a case study of an 84-year-old woman. After bright light treatment, the patient entered full remission of chronic SAD symptoms. In contrast, however, a bright versus dim light crossover design, by Genhart, Kelly, Coursey, Datiles, and Rosenthal (21), reported negative results. After bright light administration, nondepressed elderly women reported feeling more irritable, anxious, and agitated (21). These findings support earlier research in younger nonclinical populations (22)(23)(24) showing no therapeutic effect by bright light treatment. Noteworthy in the research by Genhart and colleagues (21) is that subjects were treated with 2500 lux for 5 hours (2.5 hours in the morning, and 2.5 hours in the evening) each day, heavily intruding on the participants' daily schedules, which may have contributed to the negative findings. Also using 2500 lux but limiting duration to 2 hours per day, Lovell, Ancoli-Israel, and Gevirtz (25) reported a decrease in evening agitation (sundowning) among institutionalized demented elderly. Fukuda and colleagues (26), using 6000 lux for 30 minutes per day, found no negative effects on mood among a sample of healthy elderly subjects. These results, taken together, suggest bright light treatment may affect mood in the elderly but that the outcome may depend on how the treatment is administered and what population (i.e., normal, institutionalized, depressed, etc.) is being treated.

Thus far, research measuring the effects of bright light therapy on depression in the institutionalized setting has not been investigated. Therefore, the present study, although not targeting older adults with SAD, focused on the underlying commonalities in light deprivation shared between SAD patients and older adults residing in the institutionalized setting. Testing the hypothesis that chronic light deprivation might be responsible, at least in part, for some depression, the aim of this study was to investigate the effects of bright light treatment on depression among institutionalized older adults.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
Subjects
The original participants were 11 wheelchair-bound older adults (80% white) residing in a long-term care facility (seven women and four men). The ages of the participants ranged from 67 years to 94 years, with a mean age of 83.8 years (SD = 9.56). Education level (grade completed) ranged from the 8th to 14th grade, with a mean grade completed of 10.9 (SD = 2.13). The participants' numbers of illnesses (number of official diagnoses) ranged from two to eight (M = 5, SD = 1.83), with 64% of the participants diagnosed with arteriosclerotic heart disease, 45% with arthritis, 27% with hypothyroidism, 27% with stroke, and 27% with peptic ulcer disease. Length of institutionalization ranged from 76 months to 1 month, with a mean of 21.65 months (SD = 23.6). The participants' previous occupations included railroad workers, business owners, housewives, and a shed worker.

All participants were required to possess a mentally autonomous state (deemed with capacity by physician or nursing-home staff) with the ability to voluntarily participate in the study. During preliminary screening, residents previously diagnosed with primary degenerative dementia or multi-infarct dementia and residents on photosensitizing medications (e.g., phenothiazine, imipramine, porphyrins, chloroquine, hydrochlorothiazide, and lithium) were ineligible. Residents on antidepressants as well as those with preexisting retinal problems were also excluded. All participants were also required to obtain a medical clearance from an ophthalmologist or optometrist and from a physician authorizing the administration of bright light treatment. All participants gave informed consent before each treatment in accordance with guidelines set by the National Institutes of Health and the Human Subjects Institutional Review Board. One participant withdrew from the study after receiving only one treatment of bright light, and her data were not included in the analysis. Consequently, 10 patients completed the study.

Apparatus
The light fixture used to administer bright light treatment was the Brite Lite III, by Apollo Light Systems, Inc. (1 ft x 2 ft, Orem, Utah; 1 ft = 30.48 cm). All components of the Brite Lite III exceeded clinical standards and were UL approved. For optimum safety to be ensured, the light boxes were further tested to assess that the energy output was within the manufacturer's specification. Outside and inside light measurements were taken with a spectroradiometer (International Light, Inc, Newbury Port, MA).

Procedure and Materials
In a placebo controlled, crossover design, participants were placed under varying light conditions. Each of the light conditions consisted of light treatment for 30 minutes per day, scheduled between 9:00 AM and 12:30 PM, with each participant receiving light treatment (both 300 and 10,000 lux) at the same time of the day across each of the light conditions (i.e., participant 1 received 300 lux at 9:00 AM, 10,000 lux at 9:00 AM; participant 2 received 300 lux at 9:30 AM, 10,000 lux at 9:30 AM, etc.). In randomized order, all participants received each of the following: (a) 1 week of 10,000 lux (treatment—therapeutic dose); (b) 1 week of 300 lux (placebo); and 1 week of no treatment (control). Each week of light treatment lasted 5 days (e.g., Monday through Friday), with a wash-out period consisting of 1 week between treatments, making total participation time in the study 6 weeks for each participant. The experiment was conducted in late April and early May.

The Geriatric Depression Scale (GDS), given verbally (27), was used to measure depression before (pretest) and after (posttest) each 5-day period of each condition. The no treatment condition (control) consisted of the administration of a pretest on Monday and a posttest on the following Friday. No light therapy or any other intervention took place during the no-treatment condition. In the 10,000 and 300 lux conditions, the GDS was administered to each participant just prior to the light treatment condition on Monday and immediately following the last treatment on Friday. All GDS scales were administered by the researcher at the same time in all treatment conditions, and light therapy was administered by a research assistant.

In a specially designated room, free from distractions in the long-term care facility, each participant was placed 20 in. (50.8 cm) in front of the light box and remained seated in his or her wheelchair while receiving light treatment. For the placebo light condition, the Brite Lite III was fitted with a neutral density filter on the inside of the diffusion screen (not apparent to the participant or the light administrator), reducing the output to 300 lux. As a way to ensure the retinal peripheral processing that has been found to facilitate the most effective treatment (28), each participant was instructed not to stare directly at the light source and was asked to only momentarily gaze up at the light source at 10-minute intervals. Further, the light administrator monitored the participants to ensure a forward head position and open eyes. During each light treatment session, reading material was available (a variety of magazines).

Statistical Analysis
A repeated measures analysis of variance (ANOVA) was used to analyze the differences between pretest and posttest GDS in the three conditions (29). Tukey's Honestly Significant Difference (HSD) test was used for post hoc comparisons (30). Pearson-product-moment correlations (30) were used to analyze the relationship between months institutionalized and GDS scores.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
Measurements taken from the light box in the treatment and placebo conditions, compared with the fluorescent lighting in the nursing home and outside sunlight, showed that the fluorescent lighting in the nursing facility produced relatively more light in the short wavelengths than either outside sunlight or the light boxes (Fig. 1). More importantly, the spectral output of the light box, although more irregular, produced wavelengths more similar to those of natural sunlight in comparison with the fluorescent lighting in the nursing home.



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  		Figure 1. Measurements taken from the light box ({blacksquare}), compared with the fluorescent lighting in the nursing facility ({diamond}), and outside sunlight (•). All measurements were taken 50 cm from the light source, except for the sunlight, which was taken with the axis of the spectroradiometer aimed at the zenith of the sun at an elevation of 3300 ft. In each case the measurements were made at least twice from 350 nm (ultraviolet B range) to 700 nm (deep red), in 10-nm increments blazed at 240 nm. The readings obtained were in watts per square centimeter per nanometer, which were then converted to relative intensity for comparison. The comparisons shown are from 400 nm (blue) to 700 nm, which is considered to be the normal visible spectrum for humans. Each set of measurements has been set to a relative height of 1.0 for comparison. The spectral output of the light box, although more irregular, produced wavelengths more similar to that of natural sunlight in comparison to the fluorescent lighting in the nursing home.

 
There were no differences between mean pretest scores (Table 1 ) at entry into the three treatment conditions. The mean pretest GDS score, all pretests for all treatments combined, was 14.76 (SD = 2.66, range = 9). The mean pretest GDS score was highly correlated to months of institutionalization (r = .81; p < .01), showing greater depression with longer institutionalization.


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  		Table 1. Pretest and Posttest Means and Standard Errors for the GDS During Various Conditions

 
A Test (pretest vs posttest) x Condition (control, 300 lux, 10,000 lux) repeated measures ANOVA revealed significant main effects for both test, F (1,45) = 9.38, p < .01, and condition, F (2,45) = 17.38, p < .01 (Table 1 ). The Test x Condition interaction was also significant, at F (2,45) = 21.2, p < .01. Post hoc analyses showed that depression scores remained unchanged during the control and placebo conditions, but depression scores decreased significantly during the 10,000 lux treatment (Fig. 2).



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  		Figure 2. Pretest versus posttest scores on the Geriatric Depression Scale in the control ({blacksquare}), 300 lux ({triangleup}), and 10,000 lux (•) conditions. Lower scores indicate less depression. Posttest scores significantly decreased ( p < .01) after the 10,000 lux treatment.

 
GDS pretest scores were also significantly correlated to difference scores between pre- and posttest 10,000 lux GDS scores (r = .62; p < .05), where more improvement was related to higher depression before treatment.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
To our knowledge, this was the first test of antidepressant effects of bright light treatment in an institutionalized older adult population. It is interesting to note that, although none of the participants were clinically diagnosed with depression, all pretest scores fell within the range of moderate to severe depression, scores of 11–20 on the Geriatric Depression Scale (27). This apparently high level of depression is consistent with previous studies reporting the inaccurate diagnosis of depression in institutionalized settings (31)(32)(33)(34). It is encouraging that participants in this study who scored higher on the GDS at baseline also showed greater improvement during the 10,000 lux treatment. In this sample, 10,000 lux for 30 minutes per day for 5 days produced a clinically important effect. The mean posttest score of 11.3 indicates that the group as a whole approached the normal range of 10 or less (27). After 10,000 lux treatment, 50% of the participants scored in the normal range.

In SAD patients, therapeutic effects have been noted after only one session, or, in contrast, to take as long as 12 sessions at 10,000 lux, 30 minutes daily. As the protocol for this study exposed older adults to 5 days of treatment at 10,000 lux, 30 minutes daily, therapeutic dosages of light treatment in the present study appear consistent with therapeutic dosages shown to be effective in SAD patients. Not surprisingly, as treatment was found effective in the 10,000 lux and not in the 300 lux (placebo) condition, light dosage and duration appears to be an important factor. Another issue to consider is the spectral representation of bright light treatment. Although findings are inconsistent as to the critical wavelengths needed for antidepressant effects among the SAD population, Lam and colleagues (35) and others (36) reported no added antidepressant effects with the addition of the ultraviolet A (UV-A) spectra. Results from the light readings in the present study support the results of Lam and colleagues (35) and Lee and colleagues (36), as output of the light box produced wavelengths more similar to those of natural sunlight at the 540-nm and 610-nm range, which may have contributed to the treatment outcome. Further research investigating the importance of spectral representation during bright light treatment for institutionalized adults is needed.

Our findings are, however, contrary to those reported in Genhart and colleagues (21), where positive effects on mood (Hamilton Rating Scale for Depression) were found at the 300 lux treatment given for 5 hours per day in healthy noninstitutionalized older women. In Genhart and colleagues, the women were not clinically depressed, as they had an average score of 7.2 on the Geriatric Depression Scale prior to exposure to 300 lux, well within the normal range (27). It may be that lower light levels are sufficient for positive effects on mood in older adults who are not clinically depressed. Or, it may be that depressed institutionalized older adults, who are more apt to suffer from light deprivation, require higher doses of bright light to gain therapeutic effects. It is important to note that participants in the present study who were institutionalized longer also tended to score higher on the Geriatric Depression Scale at baseline, and, furthermore, the most depressed participants tended to experience the greatest improvement from the 10,000 lux treatment.

Only one participant discontinued bright light treatment, reporting that the light was too bright. No other side effects (e.g., eye strain, headaches, or dizziness) were reported. As compared with the administration of psychotropic medication with serious side effects (e.g., orthostatic hypotension, cardiac arrhythmias, altered cardiac rates, and sedative states), the absence of serious side effects in bright light treatment is encouraging. It should be noted, however, that the lack of side effects in this study could be a result of the short duration and limited exposure to the 10,000 lux treatment. Further, because reports of side effects depended on spontaneous reports, side effects may have been experienced but not reported. For the institutionalized older adult population, future protocols should extend treatment trials to assess side effects associated with prolonged use.

The inclusion and exclusion criteria in this study were relatively stringent. Therefore, generalization of these results may be limited to moderately to severely depressed (whether diagnosed or not) institutionalized older adults with good cognitive and retinal functioning, and to those who have not suffered severe deterioration in either the mental or biological realms. Other limitations to the present study include the small sample size and the data gathered from only one facility, which did not allow for statistical examination of order effects of treatment. Additionally, participants' seasonal variations (mood and behavior change during the seasons) were not assessed. Consequently, it is not known how the participants' patterns of seasonal variation might have been related to the outcome of treatment.

The results of the present study suggest that bright light treatment may be effective in some institutionalized populations, providing nonpharmacological intervention in the treatment of depression among older institutionalized adults. Furthermore, the length of institutionalization may play an important role in determining the efficacy of bright light treatment for older adults in the nursing-home setting.


   Acknowledgments
 
This research was submitted in partial fulfillment for the Master of Arts Degree and was supported by the Office of Sponsored Projects, California State University, Bakersfield and by the National Institute of Neurological Disorders and Stroke, under National Research Service Award NIH 1F31NS10811-0. We thank Barbara Bennett for her assistance in administering the light therapy, the nursing home staff, and, most important, the participants.

Received September 26, 1999

Accepted June 1, 2000


   References
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 Abstract
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 References
 

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