Agomelatine is a promising new antidepressant being developed by Servier in Europe and Novartis in the USA. It is an oral melatonin receptor stimulator and a serotonin receptor blocker. Many experts think that its antidepressant effect is achieved primarily through its effects on serotonin receptors, but some think that the melatonin effect also contributes to the antidepressant effect. It has been shown to be effective in shifting circadian rhythms in humans and that might make it helpful for treatment of SAD, but this remains to be tested.
The evidence supporting the usefulness of serotonergic drugs (SSRIs) for SAD is very limited. Glaxo’s Wellbutrin XL (which has combined dopaminergic, serotonergic, and norepinephrine-receptor-blocking action), and is currently on the market, was approved by FDA in 2006 for the prevention of SAD. It was already on the market for the treatment of major depression (including SAD). All things considered, a drug that works for one kind of depression is likely to work for other types as well.
On the other side of the coin, the environmental therapies — light and negative air ionization — originally developed for treatment of SAD have now been shown also to work for non-seasonal depression. Indeed, recent clinical work shows that some patients (seasonal or non-seasonal) who have failed to respond to drugs — “medication-resistant” cases — respond well to light therapy. Finally, in cases of partial response to drugs or light therapy, their combination can be effective.
Patients can inquire about the sliding-scale Residents’ Clinic at Columbia University Medical Center by calling the referral line, 212-305-6001. If that program is not suitable, the patient will be given additional leads. There are also opportunities at the New York State Psychiatric Institute for participation without cost in bipolar depression research studies that provide excellent care. Again, call the referral line.
Quoting from Dr. Terman’s 2005 CNS Spectrums review (downloadable at www.cet.org): “Light therapy for elderly patients deserves separate mention. Although its use to alleviate disruptive and cognitive symptoms of senile dementia has been extensively investigated, a review of the effect on sleep and behavior found the results inconclusive, with further confirmation in another Cochrane review that also considered effects on mood. Few light therapy studies have focused on geriatric depression, per se. A small crossover study (N=10) in institutionalized patients without MDD but with moderate-to-high Geriatric Depression Scale scores tested morning bright versus dim light (10,000 lux versus 300 lux, 30 minutes, 5 days), and obtained significant mood improvement under the active condition. In Taiwan, a trial of hospitalized patients with MDD (N=30) found alleviation of depressive symptoms after 5 days of morning light treatment (5000 lux, 50 minutes) in comparison with an untreated control group. However, the largest such trial (N=80, 5 weeks) found no significant benefit of bright light (10,000 lux, 1 hour; morning, midday, or evening) over a 10-lux dim red control. This raises doubt about the general utility of bright light therapy for geriatric depression, even though there was a trend toward greater improvement with morning exposure.” See the references in the paper, and you will have a route into the literature.
No one has ever demonstrated that light therapy buffers against depression in non-depressed people, although that is conceivable. Not to throw cold water on your doctors’ strategy, but it is also possible they think using a light box would help maintain your good mood through its placebo effect. However, if difficulty awakening has been one of your problems even when you’re feeling well, the light box could be useful. And the light box can be used in conjunction with meds to enhance overall response–that is, to reduce the residual symptoms that meds fail to treat. If your historic problem is winter-seasonal, it makes sense to discontinue lights in early May, but if your historic problem is non-seasonal, whatever benefits you are finding with light could last year-round. Obvious strategy: if you begin to slump when you discontinue the lights, resume them!
You’re on the right course: the primary treatment for summer depression remains standard antidepressant drugs. You are smart to wean yourself off Paxil in the fall, but you should resume it in late spring in order to try to prevent the next summer’s relapse. Some people with summer depression find relief in strongly air conditioned environments (and, believe it or not, by taking frequent cold showers)–but these measures are temporary, and mood and energy can plummet as soon as you go outdoors. It is also worth testing whether heavily filtered wrap-around sunglasses provide relief, although this method has been used mainly by people who become “hyper” or agitated each summer.
This is an unusual report, but there are some possible explanations. Some people experience “photophobia”–with very disruptive reactions to bright light exposure, which may be related to hypersensitivity of the retina of the eye, psychological factors, or both. If you use a photosensitizing medication, that may be responsible. There have been scattered reports of people becoming very sleepy during and after bright light exposure; it is not clear whether this is due to the time of day of light exposure. Possibly, your reaction to outdoor sunlight is triggered by the strong blue component of white light. If so, you may benefit by using blue-blocking wrap-around glasses, such as Model 58 from http://noirmedical.com/uv_yellow.htm#Light. Finally, you may be suffering from summer depression, which is more plausibly related to high heat and humidity than bright light.
Aerobic exercise can indeed complement the antidepressant and energizing effect of light therapy. Problem is, many people suffering depression cannot garner the motivation to maintain a regular exercise regimen. We suggest first starting with bright light therapy, and as its beneficial effect sets in, taking the opportunity to begin a daily aerobic routine. As for diet, regular healthy measures are all we would suggest. Once the antidepressant effect from light (or light + exercise) sets in, it becomes far easier to control excessive carb intake.
First of all, we do not recommend self-treatment of major depression or bipolar disorder. There are too many interacting factors that need to be sorted out by a clinician–and although it is possible that you will experience improvement without such guidance and monitoring, if you don’t, you are not in the best position to decide next steps on your own. We can generalize about some factors that might be operating in your situation, however. Patients with bipolar disorder should use light therapy only after establishing a steady dose of a mood-stabilizing drug (examples: lithium, Depakote). Otherwise, they are vulnerable to sudden switching between extreme mood states, sometimes with rapid cycling, which can be extremely distressing. Some patients with bipolar disorder have responded preferentially to light therapy at midday rather than early morning, which is a milder treatment strategy-one which most patients with SAD do not require.
Personal Variations in Treatment
Research suggests that patients with non-seasonal depression respond more gradually to light therapy than do patients with SAD, and the clear onset of positive effect may not be apparent for several weeks. In one study of non-seasonal patients with chronic, major depression, light duration was standardized at 60 minutes at 10,000 lux, while in another study of non-seasonal bipolar disorder, very short exposures (15 minutes) appeared optimal. Some patients with non-seasonal depression respond adequately to a combination of light therapy and antidepressant drugs, while either one alone is insufficient. We hope you see why clinical management may be very important for you.
Sundowning refers to agitated, often disruptive behavior during a regular period each afternoon or evening, seen in some elderly patients with dementia. Patients with dementia also often show the other symptoms you mention. Although the research literature is divided on whether light therapy would alleviate symptoms, we think a standard schedule of morning light therapy is well worth a try. An issue is compliance — that is, will the patient with dementia sit for a light therapy session? In most cases, sessions will have to be monitored and supervised by an aide or family member. Since it is possible that light therapy will not be tolerated by the patient, the procedure should be undertaken only with a doctor’s guidance.
Light therapy can be helpful for wintertime flare-ups of ADD and depression. If you use a 10,000 lux light box that strictly filters out ultraviolet light and attenuates blue — see our recommendation at the CET Store, www.cet.org/store — no problems are anticipated using concomitant prescription medications. (Still, you should watch out for unexpected side effects.) Yes, indeed, the energy enhancement from light therapy will be healthier than the agitation of ADD!!