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BRIEF REPORTS

Greater Improvement in Summer


Than With Light Treatment in Winter in Patients
With Seasonal Affective Disorder
Teodor T. Postolache, M.D., Todd A. Hardin, M.S., Frances S. Myers, R.N., M.S.N.,
Erick H. Turner, M.D., Ludy Y. Yi, Ronald L. Barnett, Ph.D., Jeffery R. Matthews, M.D.,
and Norman E. Rosenthal, M.D.

Objective: The authors sought to compare the degree of mood improvement after light
treatment with mood improvement in the subsequent summer in patients with seasonal affective disorder. Method: By using the Seasonal Affective Disorder Version of the Hamilton
Depression Rating Scale, the authors rated 15 patients with seasonal affective disorder on
three occasions: during winter when the patients were depressed, during winter following
2 weeks of light therapy, and during the following summer. They compared the three conditions by using Friedmans analysis of variance and the Wilcoxon signed ranks test. Results: The patients scores on the depression scale were significantly higher after 2 weeks
of light therapy in winter than during the following summer. Conclusions: Light treatment
for 2 weeks in winter is only partially effective when compared to summer. Further studies
will be necessary to assess if summers light or other factors are the main contributors to
this difference.
(Am J Psychiatry 1998; 155:16141616)

ight therapy is an effective antidepressant for the


winter depressive symptoms in patients with seasonal
affective disorder (13). Although clinical experience
suggests that mood improvement following light treatment is smaller than the spontaneous improvement
during summer, this difference has never been formally
documented.
METHOD
We recruited patients with seasonal affective disorder by newspaper and radio advertising in the metropolitan Washington, D.C.,
area. Patients met the criteria of Rosenthal et al. for seasonal affective disorder (1) and DSM-IV criteria for a past major depressive episode. The criteria of Rosenthal et al. require at least one past major
depressive episode and at least 2 consecutive years in which depression developed in fall or winter and remitted in spring or summer. To
start light treatment, a subject had to have a typical depressive score
Received Nov. 3, 1997; revisions received April 16 and May 20,
1998; accepted July 9, 1998. From the Clinical Psychobiology
Branch, NIMH. Address reprint requests to Dr. Postolache, Section
on Biological Rhythms, NIMH, Bldg. 10, Rm. 3S231, Bethesda,
MD 20892; postolache@nih.gov (e-mail).
Supported by the NIMH intramural research program.
The authors thank Thomas Wehr, M.D., for reviewing an early
draft of the article; Holly Lowe, M.S.W., and Kathleen Dietrich,
R.N., for screening and rating patients; and Karen Pettigrew,
Ph.D., for statistical consultation.

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of at least 14 or a minimum typical score of 12 with a total depressive score of at least 20 on the Hamilton Depression Rating Scale,
Seasonal Affective Disorder Version (4). We excluded patients if they
had comorbid axis I psychiatric conditions or medical problems or
were taking psychotropic medication. Twenty-two patients were eligible, of whom 15 were enrolled in this study (two patients required
antidepressants when they did not respond to light, one underwent
surgery, and four were unavailable for follow-up). Patients signed informed consent forms. Their mean age was 44.2 years (SD=10.6).
Eleven (73.3%) were women and four (26.7%) were men. Nine patients (60%) had unipolar depression, and six (40%) had bipolar
disorder.
We rated mood by administering the Hamilton Depression Rating
Scale, Seasonal Affective Disorder Version (4), once during winter
when the patients were depressed, once during winter after 2 weeks
of light therapy, and once during the following summer. Response to
light was defined as at least a 50% decrease in baseline score and a
total posttreatment score of 7 or lower on the Seasonal Affective
Disorder Version of the Hamilton depression scale (5). Eight of 15
patients responded to 2 weeks of light treatment, and 13 of 15 patients responded in summer (difference not significant by McNemar
test for significance of changes, with Yatess correction for continuity: 2=2.29, df=1, 0.10<p<0.20).
Light treatment consisted of a standard regimen of 10,000-lux
cool-white fluorescent light therapy for 45 minutes twice daily. After
2 weeks of the standard regimen, the treatment was individually customized and gradually tapered in spring.
We initially analyzed the patients scores on the depression scale
by using the Friedmans two-way analysis of variance with conditions (depressed, light-treated, and summer) as factors. We then
compared typical, atypical, and total depression scores across lighttreated and summer conditions by using the Wilcoxon signed ranks

Am J Psychiatry 155:11, November 1998

BRIEF REPORTS

test. The criterion alpha (two-tailed) was set at 0.015, with a Bonferroni correction for multiple comparisons.

RESULTS

FIGURE 1. Clinical Ratings on the Seasonal Affective Disorder


Version of the Hamilton Depression Rating Scale (Scores for
Typical, Atypical, and Total Depression) in Patients With Seasonal Affective Disorder During Winter Depression, After 2
Weeks of Light Treatment, and in the Following Summer

The Friedman analysis for total scores on the depression scale showed a significant effect for condition
(Friedman test statistic=26.3, df=2, p<0.001). Similarly, we found a main effect for condition when we
applied the analysis to typical (Friedman test statistic=
24.4, df=2, p<0.001) and to atypical (Friedman test
statistic=26.23, df=2, p<0.001) scores.
Further Wilcoxon signed ranks test comparisons of
light-treated and summer conditions showed that depressive scores were significantly lower in the summer
than after light therapy (figure 1). The median total depression score (30 in depressed state) fell from 7 in the
light-treated condition to 3 in the summer (T=5, N=14,
p<0.01) The median typical depression score (16 in depressed state) fell from 5 in light-treated condition to 2
in the summer (T=16, N=15, p<0.01). The median
atypical depression score (10 in depressed state) decreased from 4 in light-treated condition to 1 in the
summer (T=4, N=14, p<0.01).
DISCUSSION

To our knowledge, this is the first report suggesting


that mood improvement with conventional light treatment in depressed patients with seasonal affective disorder is not as complete as the spontaneous remission
occurring in summertime. In order to verify the seasonal pattern of seasonal affective disorder in participants in a light-treatment study, Magnusson and Kristbjarnarson (6) rated nine patients with seasonal
affective disorder in the summer following light treatment but found no statistically significant difference in
the depressive scores between postlight and summer
conditions, possibly because of insufficient statistical
power.
Our finding cannot be explained in terms of the development of summer hypomania in bipolar patients.
First, hypomanic symptoms would tend to increase
rather than decrease the typical depressive symptoms.
Second, we examined post hoc, separately in unipolar
and bipolar patients, the changes in mood between the
light-treated and summer conditions; the results in the
two subgroups were very similar. The small sizes of
these subgroups do not, however, allow for a proper
statistical analysis. Such an analysis might be accomplished by future studies on larger groups.
We recognize that there is an ordering effect that
may have confounded our result, given that all subjects
received light therapy before the arrival of summer. It
is, therefore, possible that our finding is due to an
overall trend toward improvement with time. It is also
possible that a longer trial of light therapy may have
yielded effects comparable to those of summer as it has
Am J Psychiatry 155:11, November 1998

a =Median

depression score. Significant condition effect (Friedman test statistic=24.4, df=2, p<0.001). Significant difference between light-treated and summer (Wilcoxon T=16, N=15, p<0.01).
b Significant condition effect (Friedman test statistic=26.23, df=2,
p<0.001). Significant difference between light-treated and summer (Wilcoxon T=4, N=14, p<0.01).
c Significant condition effect (Friedman test statistic=26.3, df=2,
p<0.001). Significant difference between light-treated and summer (Wilcoxon T=5, N=14, p<0.01).

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BRIEF REPORTS

been suggested that further gains are seen beyond 2


weeks treatment (7). Nevertheless, the amount of light
treatment given in this study is equivalent to, or greater
than, that given in most clinical trials (5, 8). Moreover,
in our study, the rate of response in summer according
to the Terman et al. criteria (5) was 86%, which is superior to the 67% response rate after 4 weeks of light
therapy reported by Bauer et al. (7).
A number of factorsfor example, the summer-winter differences in photoperiod, light intensity, and
amount of ultraviolet radiation reaching the eye and
skinmight have contributed to the superior antidepressant effects of summer as compared with light
therapy. Consistent with this last suggestion is a recent
report on the possible influence of light exposure to
skin on circadian rhythms (9). Besides light, other
physical factors, such as temperature, as well as chemical, biological, and socioeconomic variables, differ between winter and summer and may have an effect on
mood and behavior. The influence of these factors on
patients with seasonal affective disorder may well be
worth studying in their own right.

2.

3.
4.

5.

6.

7.

8.

REFERENCES
1. Rosenthal NE, Sack DA, Gillin CJ, Lewy AJ, Goodwin FK,
Davenport Y, Mueller PS, Newsome, DA, Wehr TA: Seasonal

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9.

affective disorder: a description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry 1984; 41:
7280
Terman M, Terman JS: A multi-year controlled trial of bright
light and negative ions, in Abstracts of the 8th Annual Meeting
of the Society for Light Treatment and Biological Rhythms.
Wheat Ridge, Colo, Society for Light Treatment and Biological
Rhythms, 1996, p 1
Eastman CI, Young MA, Fogg LF, Lui L: Light therapy for winter depression is more than a placebo. Ibid, p 5
Williams JBW, Link MJ, Rosenthal NE, Terman M: Structured
Interview Guide for the Hamilton Depression Rating Scale,
Seasonal Affective Disorder Version (SIGH-SAD). New York,
New York State Psychiatric Institute, 1988
Terman M, Terman JS, Quitkin F, McGrath P, Stewart J, Rafferty B: Light treatment for seasonal affective disorder: a review of efficacy. Neuropsychopharmacology 1989; 2:122
Magnusson A, Kristbjarnarson H: Treatment of seasonal affective disorder with high-intensity light: a phototherapy study
with an Icelandic group of patients. J Affect Disord 1991; 21:
141147
Bauer MS, Kurtz JW, Rubin LB, Marcus JG: Mood and behavioral effects of four-week light treatment in winter depressives
and controls. J Psychiatr Res 1994; 28:135145
Terman M, Amira L, Terman JS, Ross DC: Predictors of response and nonresponse to light treatment for winter depression. Am J Psychiatry 1996; 153:14231429
Campbell SS, Murphy PJ: Extraocular circadian phototransduction in humans. Science 1998; 279:396399

Am J Psychiatry 155:11, November 1998

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