Evidence for the Efficacy of Bright Light Therapy for Bipolar Depression

LETTERS Letters to the Editor Evidence for the Efficacy of Bright Light Therapy for Bipolar Depression TO THE EDITOR: The article by Sit and colleagues (1), pub- lished in the February 2018 issue of the Journal, reports the high efficacy of antidepressant midday light treatment for bipolar disorder. Bipolar depression is a difficult-to-treat condition, with low success rates of antidepressant drugs (2). We thus welcome midday light treatment as a new treatment option. However, the study infers that antidepressant morning light treatment of bipolar depression can trigger mixed states (3) or is equal to placebo (4), so that its use is contraindicated. We should not lose sight of a large body of evidence demonstrating that morning bright light treatment for bipolar depression is efficacious and safe. This has been highlighted in a meta-analysis (5) and in two recent randomized placebocontrolled trials (6, 7). Furthermore, a historical review (8) of 41 studies published between 1982 and 2017 administering light treatment to 799 patients with bipolar depression, mostly in the morning, showed that the rate of switch is lower than the 4% switch rate expected during placebo treatment of bipolar depression (9), thus not justifying specific concerns about manic switches after light treatment. Morning timing appears to have been forgotten, leading to an uncomfortable and unjustified either/or situation for midday or morning light treatment. We wish to emphasize, in the absence of trials directly comparing midday and morning light treatment, that because of its proven efficacy and safety, early morning bright light treatment for bipolar depression, as many of us have used it in everyday clinical practice as an antidepressant adjunct to mood stabilizers, should be recognized as a valid treatment option. REFERENCES 1. Sit DK, McGowan J, Wiltrout C, et al: Adjunctive bright light therapy for bipolar depression: a randomized double-blind placebocontrolled trial. Am J Psychiatry 2018; 175:131–139 2. Post RM, Leverich GS, Altshuler LL, et al: Differential clinical characteristics, medication usage, and treatment response of bipolar disorder in the US versus the Netherlands and Germany. Int Clin Psychopharmacol 2011; 26:96–106 3. Sit D, Wisner KL, Hanusa BH, et al: Light therapy for bipolar disorder: a case series in women. Bipolar Disord 2007; 9:918–927 4. Dauphinais DR, Rosenthal JZ, Terman M, et al: Controlled trial of safety and efficacy of bright light therapy vs. negative air ions in patients with bipolar depression. Psychiatry Res 2012; 196:57–61 5. 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; 26:1037–1047 Am J Psychiatry 175:9, September 2018 6. Zhou TH, Dang WM, Ma YT, et al: Clinical efficacy, onset time, and safety of bright light therapy in acute bipolar depression as an adjunctive therapy: a randomized controlled trial. J Affect Disord 2018; 227:90–96 7. Yorguner Kupeli N, Bulut NS, Carkaxhiu Bulut G, et al: Efficacy of bright light therapy in bipolar depression. Psychiatry Res 2017; 260: 432–438 8. Benedetti F: Rate of switch from bipolar depression into mania after morning light therapy: a historical review. Psychiatry Res 2018; 261: 351–356 9. Peet M: Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants. Br J Psychiatry 1994; 164: 549–550 Francesco Benedetti, M.D. David H. Avery, M.D. Michael Bauer, M.D., Ph.D. William E. Bunney, M.D. Okan Çaliyurt, M.D. Giovanni Camardese, M.D. Cristina Colombo, M.D. Sara Dallaspezia, M.D. Tone Elise Henriksen, M.D. Siegfried Kasper, M.D. Kenichi Kuriyama, M.D., Ph.D. Raymond W. Lam, M.D. Klaus Martiny, M.D., Ph.D. Ybe Meesters, Ph.D. Kazuo Mishima, M.D., Ph.D. Raphael Schulte, M.D., Ph.D. Masahiro Suzuki, M.D., Ph.D.  ˛ cicki, M.D., Ph.D. Łukasz Swie Makoto Uchiyama, M.D., Ph.D. David Veale, F.R.C.Psych., M.D. Dietmar Winkler, M.D. Joseph Wu, M.D. Nese Yorguner Kupeli, M.D. Takuya Yoshiike, M.D., Ph.D. Xin Yu, M.D., Ph.D. From the Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy; Psychiatric Medicine Associates, the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle; the Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Dresden, Germany; the Department of Psychiatry and Human Behavior, School of Medicine, University of California, Irvine; the Department of Psychiatry, School of Medicine, Trakya University, Edirne, Turkey; the Department of Psychiatry and Psychology, Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, Rome; the Department of Psychiatry, School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; the Section for Psychiatry, Department of Clinical Medicine, University of Bergen, Bergen, and the Division of Mental Health Care, Valen Hospital, Fonna Local Health Authority, Norway; the Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna; the Department of Psychiatry, Shiga University of Medical Science, Otsu, Japan; the Department of Psychiatry, University of British Columbia, Vancouver, Canada; Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen University Hospital, Copenhagen; University Center for Psychiatry, University Medical Center, Groningen, the Netherlands; the Departments of Psychophysiology and of Adult Mental Health, National Institute of Mental Health, National Center ajp.psychiatryonline.org 905 LETTERS TO THE EDITOR of Neurology and Psychiatry, Tokyo; Psychiatrist Team Alkmaar West, Alkmaar, the Netherlands; the Department of Psychiatry, Nihon University School of Medicine, Tokyo; the Department of Affective Disorders, Institute of Psychiatry and Neurology, Warsaw; Maudsley Hospital and the Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London; the Department of Psychiatry, Marmara University Hospital, Istanbul, Turkey; and the Institute of Mental Health, Peking University, Beijing. Address correspondence to Dr. Benedetti (benedetti.francesco@hsr.it). Dr. Avery has written articles for UpToDate. Dr. Henriksen is a shareholder in Chrono Chrome AS. Dr. Kasper received grants, research support, consulting fees, and/or honoraria within the last 3 years from Angelini, AOP Orphan Pharmaceuticals AG, AstraZeneca, Eli Lilly, Janssen, KRKA-Pharma, Lundbeck, Neuraxpharm, Pfizer, Pierre Fabre, Schwabe, and Servier. Dr. Lam has received speakers honoraria from the Canadian Network for Mood and Anxiety Treatments, the Canadian Psychiatric Association, Lundbeck, and Pfizer; he has been a consultant for or served on advisory boards of Akili, Allergan, the AsiaPacific Economic Cooperation, the Canadian Depression Research and Intervention Network, the Canadian Network for Mood and Anxiety Treatments, the CME Institute, Janssen, Lundbeck, Medscape, Otsuka, and Pfizer; he has received research funds (through the University of British Columbia) from the BC Leading Edge Foundation, Brain Canada, the Canadian Institutes of Health Research, the Canadian Network for Mood and Anxiety Treatments, Janssen, Lundbeck, the Movember Foundation, Pfizer, St. Jude Medical, the University Health Network Foundation, the Vancouver Coastal Health Research Institute, and the VGH Foundation; he owns a patent related to the Lam Employment Absence and Productivity Scale (LEAPS); he receives royalties from Cambridge University Press, Informa Press, and Oxford University Press; and he owns stock in Mind Mental Health Technologies. Dr. Winkler has received lecture fees from Angelini, Lundbeck, and Pfizer. The other authors report no financial relationships with commercial interests. design, lack of a comparator group, brief duration, inclusion of antidepressants with adjunctive light therapy, and light therapy combined with sleep deprivation. Assessing hypomanic or manic symptoms with a valid measure is necessary to quantify the rate of their emergence (4). Only 12 of 43 studies (3) included the administration of a mania scale, which will bias the results toward underestimating the occurrence of mixed states and hypomania. With due respect to our colleagues, the extensive list of authors who “have used [morning light therapy] in everyday clinical practice” (as have we) cannot supplant controlled clinical trial data. In his comprehensive survey (3), Dr. Benedetti reported that morning light therapy has been compared with placebo for bipolar disorder in only three studies. Using the Young Mania Rating Scale in two of the studies, symptoms were absent or rare, while the third study lacked a standard mania measure. With midday light therapy, we did not observe any mixed states, hypomania or mania, or significant differences in scores on the mania rating scale. Direct comparisons of midday and morning light therapy in a randomized controlled trial, with attention to gender-specific rates and predictors of hypomania or mania and mixed state emergence, would be a valuable contribution. Accepted March 28, 2018. Am J Psychiatry 2018; 175:905–906; doi: 10.1176/appi.ajp.2018.18020231 Light Therapy and Risk of Hypomania, Mania, or Mixed State Emergence: Response to Benedetti et al. TO THE EDITOR: We chose midday light for our randomized controlled trial of patients with bipolar disorder because of the findings from our pilot study (1). Three of our first four women with depression treated with antimanic drugs rapidly developed mixed states, which necessitated discontinuation of morning light therapy. However, we have recommended morning light therapy for patients who do not respond to 45–60 minutes of midday light therapy. The interpretation that morning light therapy is contraindicated is not consistent with our publications (1, 2). Morning light therapy can elicit abrupt, large circadian rhythm phase advances that may precipitate bipolar switching, as has been described after eastward jet travel. Midday light therapy is far less likely to induce similar phase shifts and is a conservative initial treatment. The gradual emergence of group differences in our controlled study of midday light therapy (2) contrasts with the rapid improvement often seen with morning light therapy, which may reflect the relative circadian rhythm potency associated with the timing of light therapy. The claim of “proven efficacy and safety” of early morning bright light treatment for bipolar depression is overstated. Many of the publications on morning light therapy and bipolar disorder in Dr. Benedetti’s review (3) included studies of seasonal depression and patients with both unipolar and bipolar disorder. Other studies were constrained by open trial 906 ajp.psychiatryonline.org REFERENCES 1. Sit D, Wisner KL, Hanusa BH, et al: Light therapy for bipolar disorder: a case series in women. Bipolar Disord 2007; 9:918–927 2. Sit DK, McGowan J, Wiltrout C, et al: Adjunctive bright light therapy for bipolar depression: a randomized double-blind placebo-controlled trial. Am J Psychiatry 2018; 175:131–139 3. Benedetti F: Rate of switch from bipolar depression into mania after morning light therapy: a historical review. Psychiatry Res 2018; 261: 351–356 4. Angst J, Adolfsson R, Benazzi F, et al: The HCL-32: towards a selfassessment tool for hypomanic symptoms in outpatients. J Affect Disord 2005; 88:217–233 Dorothy K. Sit, M.D. Michael Terman, Ph.D. Katherine L. Wisner, M.D., M.S. From the Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago; and the Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York. Address correspondence to Dr. Sit (dorothy.sit@northwestern.edu). The authors’ disclosures accompany the original article. Accepted March 28, 2018. Am J Psychiatry 2018; 175:906; doi: 10.1176/appi.ajp.2018.18020231r Validating the Predictive Accuracy of the NAPLS-2 Psychosis Risk Calculator in a Clinical High-Risk Sample From the SHARP (Shanghai At Risk for Psychosis) Program TO THE EDITOR: A web-based risk calculator (http://riskcalc. org:3838/napls/) for use in clinical high-risk populations was developed in the second phase of the North American Prodrome Longitudinal Study (NAPLS-2) (1). This calculator Am J Psychiatry 175:9, September 2018