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Reported September 13, 2004

Depressed Moms-to-be Brighten up -- Full-Length Doctor's Interview

In this full-length doctor's interview, Katherine L. Wisner, M.D., explains light therapy as a treatment for depression that is safe for pregnant women. Ivanhoe Broadcast News Transcript with
Katherine L. Wisner, M.D., Psychiatrist,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,
TOPIC: Depressed Moms-to-be Brighten up
Do you know why light therapy works? Dr. Wisner: Not yet. We really don't know exactly what happens in the brain. There are some hypotheses, though, such as melatonin curve changes. Melatonin is secreted typically during the night at high levels. If we look at the shift in the melatonin onset curve, we do that by looking at salivary melatonin. We know that the degree with which this curve shifts is clearly a reduction in depression symptoms. So, we know that light therapy has something to do with changing the circadian or 24-hour rhythms that occur in depression. And we know that depression disrupts all the things we take for granted, like sleeping, appetite, eating and energy level. It probably has something to do with correcting those 24-hour body rhythms in some way. What does the light have to hit to have an effect? Is it light in the face that has the effect, or light on the skin, or on the eyes? Dr. Wisner: There was a debate about this a couple of years ago because there was a finding that light didn't necessarily have to hit the eyes to have an effect on the body. One of the things that is now very clear is that light therapy has the best effect when it's delivered through the eyes because that's the most sensitive part of the body to receive light. The best time to give light therapy for most patients is within 10 minutes of awakening in the morning. Some folks will ask, "Why not just go outside a lot?" That helps but the best effect is when there's a very bright burst of light, like being outside in the middle of a bright June day. When that burst of light is delivered within 10 minutes of awakening in the morning, it seems to have the most powerful effect on reducing depression symptoms. The duration of this burst of light ranges anywhere from a half an hour to an hour. Typically, if I'm starting somebody on light treatment, I'll recommend a half an hour, unless they have bipolar disorder. For that kind of depression, I typically start with a lower dose of about 15 minutes. The light therapy for the treatment of depression works for both seasonal depression and non-seasonal depression.Why do you start with a lower dose for bipolar disorder? Dr. Wisner: Because they're really different disorders. Seasonal depression, or uni-polar depression, is the kind that we're most familiar with. It occurs about twice as commonly in women as in men. One out of five women develop it at some point in their lives. So, it's very common. Typical depression includes not sleeping well, feeling agitated, and lack of appetite. This type of depression is what we're most familiar with. Atypical depression is the sleep all the time, eats a lot, gain weight, and very fatigued type of depression. This type is less common. We now know that light works for either type of depression. Tell me about the study you are involved in.Dr. Wisner: We have two studies. The first study is light therapy for depression in pregnancy, and it's for non-seasonally depressed women. The reason for this subject is that the mainstay treatment for depression today is psychotherapy and drug therapy. Of course, for pregnant or breastfeeding women the issue of drug treatment and its potential effects on the fetus is a major concern to a lot of patients and physicians. Exploring the possibility that bright light treatment might work for depression instead of medication treatment is a major advance for pregnant patients or patients who prefer not to have psychotherapy or take drugs or who have not responded to this therapy. For the second study, we are studying depression that occurs in the bipolar illness. The advantage here is that light therapy is delivered in this burst of treatment in the morning. We can change the dose day by day. Once you treat the patients with the medicine, if they become too high, which is a risk with antidepressant treatment, you have to wait until that drug metabolizes out. It's not as malleable as changing the dose. The other issue is that in light therapy we find that if patient's dose gets too high, changing it or lowering it quickly typically results in a change in symptoms over a day or two. We can change the light and have them feel pretty good as opposed to worry they're going to begin to rapid cycle as they might on medicine. The other issue is the cost for both treatments. A light therapy box can run about $250 to $350. For many patients that's a couple of months of medication. What made you start the study? Dr. Wisner: I have colleagues at Columbia and University of California at San Diego who are light therapy researchers, or chronobiologists. They have been after me for some time to become interested in light therapy as another option for pregnant patients. About seven years ago, we had a meeting in New York, and we put together this collaborative research project. I finally became convinced that it was an effective treatment. I'm trained in rigid psychotherapies and medication treatments for depression, so these more novel therapies were a bit new to me. But after working with light and understanding more about physiology and melatonin, I've become absolutely excited about the possibility of sharing that. It's an effective treatment for depression in pregnancy. We might spare many women medication treatments during pregnancy.What has been your reaction to the results you've seen as these women have used the light therapy?Dr. Wisner: I have been quite amazed at their success at the treatments, particularly for the pregnant patients The results that we're getting are similar to what one would see in a drug study. In other words, the number of patients who respond and the rate at which they respond is similar to drug studies. We've been incredibly encouraged. Our American Psychiatric Association just finished another analysis of all the studies of light therapies for seasonal and non-seasonal depression and came up with essentially the same kind of finding after reviewing our studies. They found that light therapy seems to have the same effect as drug treatment does on depression. That's interesting for those of us in psychiatry who have only been trained in the last 20 years or so. So, it still is not a very widely used treatment. I think that's a shame, and I hope to see that change. What are the details of the study? How many centers and people are involved?Dr. Wisner: In the pregnancy light therapy study, we are entering women into this study here in Pittsburgh. Yale is also a site, as well as University of California at San Diego, which has an entirely different light area. Light experts at Columbia are doing the salivary melatonin essays to look at some biological markers to see if they can figure out what the correlations of response are and to see if that initial study that shows the changes in melatonin curves holds up in a larger sample. We are enrolling women who are newly pregnant, up to about 30 weeks of pregnancy, because the protocol lasts 10 weeks. The women come into the study with clinical depression at a moderate level. We always give a full discussion of the risks and benefits of our treatment because we don't want to imply that this is a firmly established treatment. They're then enrolled in the study.For the first five weeks we give either an active light treatment or our best guess at a control treatment that is expected to be effective by the patient but isn't typically productive. That's been hard because defining a placebo treatment for something you can see is an interesting exercise. But after those five weeks, the patients who respond to the initial five weeks of treatment will get another box at that time that is expected to be effective. Those who don't respond will get a new and different box that's expected to be effective. What risks does light therapy have?Dr. Wisner: As far as we know, there aren't any because it isn't an unnatural treatment. Anybody who is pregnant in the summer would have similar experiences with light although they wouldn't be in this early morning mode typically. We do have a very interesting hypothesis. We believe light in the atmosphere controls the mother animals' rhythms just like it does ours. Everybody knows how they feel in the winter is different from the summer and the evening is different from daylight. But what happens in animals is those same light cycles control the maternal behavior. Somehow through something that's transferred in the maternal blood, we think the fetus' rhythms become entrained to the mothers. So one of the really intriguing things we're looking at in this study is do the babies who are the offspring of mothers treated in this way have much easier cycles of birth than other newborns. In other words, are they entrained in a way that is easier post-partum? Might they have, for example, a propensity to be up during the day and sleep at night? How would that work? Because so many of us, myself included, have had babies that like to sleep all day and scream all night would really like an option that might change that sooner. How do pregnant women get more information about this treatment? Who do they contact if they are interested?Dr. Wisner: We have a number of contacts. The way we typically get those is through our Web site called http://www.womensbehavioralhealth.org. There is a place on the Web site where people can ask questions. I have a list of light therapists from the Society for Light Therapy and Biological Rhythms. If we get a woman from Missouri who says, "Gee, I'm really interested in that but I'm not close, can you recommend someone who might be willing to work with me?," we try to hook them up with a provider from that list. Getting in touch with us through the Web site is really quite useful. If people are local they can actually download a form if they're interested in being in a research study or just e-mail us. Is there anybody who should avoid light therapy?Dr. Wisner: I would be most worried about trying light therapy with people who have manic depression or bipolar illness. We have this separate study of light therapy for bipolar patients. There is some evidence that they are more influenced by light than other people. We're looking very carefully at the eyes before and after treatment, and at their likelihood becoming more high or hyper with light treatment, as they might with any antidepressant treatment. That would be a group of folks that I think would be very unwise to undertake light treatment without careful monitoring by their physician or by their mental health professional. I think everyone should be monitored for the light treatment initially. It is a potent antidepressant treatment. Giving it to yourself without understanding the risks, although minimal, and the side effects is not a good idea. We've had many patients who come in, get started, do well, know exactly how to titrate it, they get the educational instruction and become unmonitored because they've become their own experts in managing it. But that's after they've had a careful diagnosis. They've had laboratory work to rule out that they're not hypothyroid or anemic or a whole host of other medical problems that can present with depression, and they do very well. But I'm not for unmonitored light treatment at all. This article was reported by Ivanhoe.com, who offers Medical Alerts by e-mail every day of the week. To subscribe, go to: http://www.ivanhoe.com/newsalert/.END OF INTERVIEWThis information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc., or any medical professional interviewed. Ivanhoe Broadcast News, Inc., assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors in different ways; always consult your physician on medical matters.If you would like more information, please contact:
Women's Behavioral Healthcare
http://www.womensbehavioralhealth.org
Light for Depression in Pregnancy Study
http://www.pregnancylight.org/
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