New research on light therapy in bipolar disorder from the 2023 International Bipolar Conference.

Published On: 09/04/2023

Duration: 10 minutes, 55 seconds

Transcript:

KELLIE NEWSOME: Today we’ll bring you updates on light therapy from the 2023 International Bipolar Conference.

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. 

CHRIS AIKEN: I’m Chris Aiken, the editor in chief of the Carlat Report. 

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: You wanna know what really bothers people with bipolar disorder? It’s when they get emotional. Someone mistreats them and they get angry, or they experience a setback, a loss, a dream deferred, and they get sad. No different from you or me, but here’s what is different, when people with bipolar disorder get emotional someone will innocently ask them, “Did you take your medication today?”

That’s a loaded question, and part of the loading is the idea that medications are the only way to treat bipolar. So come with us to the International Bipolar Conference, and we’re going to learn that meds are rarely enough. It’s a bio-psycho-social-spiritual-environmental illness, and today we’re going to focus on one aspect of the environment: Light and Darkness. But first a recap of past lessons and a preview of the CME quiz for this episode

KELLIE NEWSOME: 

1. Screen for bipolar disorder with a tool that looks at signs and symptoms of the illness, like the Rapid Mood Screener or the Bipolarity Index

2. Use more lithium

3. Move lurasidone up in your treatment algorithms now that it’s generic, and keep Robert Post’s three L’s on the tip of your tongue for bipolar depression: Lithium, lamotrigine, and lurasidone.

4. Avoid valproate in women of childbearing age

5. When things go wrong in treatment – even if it’s because your patient is stops taking their meds – assume it is your fault. You haven’t found the meds they want to take.

6. Rate the symptoms at every visit, and find a way to visually track them to find those cyclical patterns that are the heart of bipolar illness.

7. Make it your goal to improve functioning, not just symptom reduction

You can earn CME credits through the link in the show notes. Here’s a preview of that 2-question quiz

1. Which of these techniques does NOT reduce the risk of mania with light therapy?

A. Titrating the dose slowly by 15 minutes a week

B. Delivering the light after 2:00 pm

C. Delivering the light at mid-Day, between 12:00 and 2:00 pm

D. Reducing the time in front of the lightbox

CHRIS AIKEN: I’m looking at a graph that steadily rises, it’s a comparison of depression levels with light exposure in bipolar depression. It supports something my patients often say to me when they decline to use the lightbox I’ve recommended, “I’ve found it easier to just sit in a bright room in the morning.” They are right, and they are wrong. More light does help, as this graph shows us, but the brightest indoor room is still less than 1,000 lux, and 1,000 lux is the kind of light that was used as a placebo in the clinical trials of light therapy in depression.

A proper antidepressant dose of light is 10-times stronger – 10,000 lux – and the patient needs to sit under it for 30-60 minutes. But for years light therapy was neglected in bipolar disorder because of fears that this antidepressant burst would trigger mania, and indeed it can, but the studies – which have just rolled in over the last 10 years – show the risk of this reaction is low, while the benefits are light therapy in bipolar depression are very high. How high? We’re talking effect sizes in the large range, around 0.8, which is similar to the effect of light therapy in unipolar depression.

Light therapy ought to be high up in your treatment algorithm for bipolar depression – and not just for winter depression – in most of the bipolar studies it treated depression independently of season. Light, after all, sets the circadian rhythm, which is integral to the pathophysiology of bipolar. If you’re going to use light therapy, here are some tips

1. Get the right box. Generally, the boxes that look good don’t work, and the ones that work don’t look good. They are big and bulky. I keep a list of boxes that passed the test in clinical trials on my website, moodtreatmentcenter.com/products, or use the trusted sources from the center for environmental therapeutics, www.cet.org.

2. Keep it close range. Check the instructions on the box, but for most products the patient needs to sit 12-14 inches from the screen. The benefits drop exponentially as they step away. And don’t look straight into the light – we’re trying to imitate the sun here, so the screen should sit angled above their head.

3. Manage any mixity. You’re unlikely to see full mania with light therapy, but they might get agitated, hyper, or irritable. If so, lower the dose, say to 15 minutes instead of an hour. You can also reduce the risk of mania by raising the dose slowly, starting at 15 minutes/day and raising by 15 minutes each week toward the target of an hour, and by giving the light therapy at lunchtime, between 12:00 pm and 2:00 pm. That midday dose is safer, but early morning dosing has also been safely used in bipolar disorder, and in general early morning doses – between 5 am and 8 am – have a stronger antidepressant effect.

KELLIE NEWSOME: Dr. Aiken forgot a key rule with light therapy – don’t use the box after 2:00 pm. Evening light will flip their circadian rhythm the wrong way, causing mania, insomnia, and even raising the risk of depression. And that brings us to update our next update, use dark therapy at night for mania. We’ll cover that in our next episode, for now, the study of the day:

Trazodone for sleep disturbance in opioid dependent patients maintained on buprenorphine: A double blind, placebo-controlled trial

Insomnia is common in substance use disorders, particularly during the early phases of sobriety. This is not an easy situation, as most hypnotics have addictive qualities, and many raise the risk of fatal overdoses in people on opioid replacement therapies. Behavioral approaches are the ideal, but it’s an ideal that often falls short of reality for these patients. That is why many clinicians turn to trazodone, the non-addictive antidepressant, even though there’s little evidence to support its use in this population.

This new study brings needed reassurance that we aren’t just dispensing a placebo here. The researchers compared trazodone to a placebo in 51 outpatients with opioid use disorder (on maintenance addiction therapy). The main outcome was the Pittsburgh Sleep Quality Index, a self-report measure that captures a broad swath of symptoms that patients care about. After 1 month of treatment, only 16% on placebo had a reduction in the Pittsburgh Index below 5, compared to 82% on trazodone.

KELLIE NEWSOME: Join the conversation and get daily research updates from Dr. Aiken’s Daily Psych feed, now available on Facebook, and as always on LinkedIn, Twitter, and Threads– just search for ChrisAikenMD.

KELLIE NEWSOME: Earn CME for this episode from the link in the show notes, and get $30 off your first year’s subscription to the full journal with the promo code PODCAST. The Carlat Report is one of the few CME publications that depends entirely on subscribers. Thank you for helping us stay free of commercial support. 

__________

The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.