Light therapy for preventing seasonal affective disorder

Barbara Nussbaumer; Angela Kaminski‐Hartenthaler; Catherine A Forneris; Laura C Morgan; Jeffrey H Sonis; Bradley N Gaynes; Amy Greenblatt; Jörg Wipplinger; Linda J Lux; Dietmar Winkler; Megan G Van Noord; Julia Hofmann; Gerald Gartlehner

doi:10.1002/14651858.CD011269.pub2

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Figure 1

PRISMA flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for the included study.

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Analysis 1.1

Comparison 1 Bright light therapy vs no light therapy, Outcome 1 Incidence of SAD (per protocol analysis).

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Analysis 1.2

Comparison 1 Bright light therapy vs no light therapy, Outcome 2 Incidence of SAD (ITT, assuming no dropout was depressed).

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Analysis 1.3

Comparison 1 Bright light therapy vs no light therapy, Outcome 3 Incidence of SAD (ITT, assuming all dropouts were depressed).

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Analysis 1.4

Comparison 1 Bright light therapy vs no light therapy, Outcome 4 Incidence of severe SAD (per protocol analysis).

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Analysis 1.5

Comparison 1 Bright light therapy vs no light therapy, Outcome 5 Incidence of severe SAD (ITT, assuming no dropout was depressed).

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Analysis 1.6

Comparison 1 Bright light therapy vs no light therapy, Outcome 6 Incidence of severe SAD (ITT, assuming all dropouts were depressed).

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Analysis 1.7

Comparison 1 Bright light therapy vs no light therapy, Outcome 7 Overall rate of discontinuation.

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Analysis 2.1

Comparison 2 Infrared light therapy vs no light therapy, Outcome 1 Incidence of SAD (per protocol analysis).

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Analysis 2.2

Comparison 2 Infrared light therapy vs no light therapy, Outcome 2 Incidence of SAD (ITT, assuming no dropout was depressed).

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Analysis 2.3

Comparison 2 Infrared light therapy vs no light therapy, Outcome 3 Incidence of SAD (ITT, assuming all dropouts were depressed).

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Analysis 2.4

Comparison 2 Infrared light therapy vs no light therapy, Outcome 4 Incidence of severe SAD (per protocol analysis).

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Analysis 2.5

Comparison 2 Infrared light therapy vs no light therapy, Outcome 5 Incidence of severe SAD (ITT, assuming no dropout was depressed).

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Analysis 2.6

Comparison 2 Infrared light therapy vs no light therapy, Outcome 6 Incidence of severe SAD (ITT, assuming all dropouts were depressed).

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Analysis 2.7

Comparison 2 Infrared light therapy vs no light therapy, Outcome 7 Overall rate of discontinuation.

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Analysis 3.1

Comparison 3 Light therapy (bright white and infrared) vs no light therapy, Outcome 1 Incidence of SAD (per protocol analysis).

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Analysis 3.2

Comparison 3 Light therapy (bright white and infrared) vs no light therapy, Outcome 2 Incidence of SAD (ITT, assuming no dropout was depressed).

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Analysis 3.3

Comparison 3 Light therapy (bright white and infrared) vs no light therapy, Outcome 3 Incidence of SAD (ITT, assuming all dropouts were depressed).

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Analysis 3.4

Comparison 3 Light therapy (bright white and infrared) vs no light therapy, Outcome 4 Incidence of severe SAD (per protocol analysis).

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Analysis 3.5

Comparison 3 Light therapy (bright white and infrared) vs no light therapy, Outcome 5 Incidence of severe SAD (ITT, assuming no dropout was depressed).

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Analysis 3.6

Comparison 3 Light therapy (bright white and infrared) vs no light therapy, Outcome 6 Incidence of severe SAD (ITT, assuming all dropouts were depressed).

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Analysis 3.7

Comparison 3 Light therapy (bright white and infrared) vs no light therapy, Outcome 7 Overall discontinuation.

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Analysis 4.1

Comparison 4 Bright light therapy vs infrared light therapy, Outcome 1 Incidence of SAD (per protocol).

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Analysis 4.2

Comparison 4 Bright light therapy vs infrared light therapy, Outcome 2 Incidence of SAD (ITT, assuming no dropout was depressed).

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Analysis 4.3

Comparison 4 Bright light therapy vs infrared light therapy, Outcome 3 Incidence of SAD (ITT, assuming all dropouts were depressed).

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Analysis 4.4

Comparison 4 Bright light therapy vs infrared light therapy, Outcome 4 Incidence of severe SAD (per protocol).

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Analysis 4.5

Comparison 4 Bright light therapy vs infrared light therapy, Outcome 5 Incidence of severe SAD (ITT, assuming no dropout was depressed).

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Analysis 4.6

Comparison 4 Bright light therapy vs infrared light therapy, Outcome 6 Incidence of severe SAD (ITT, assuming all dropouts were depressed).

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Analysis 4.7

Comparison 4 Bright light therapy vs infrared light therapy, Outcome 7 Overall discontinuation.

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Summary of findings for the main comparison. Bright white light therapy compared with no light therapy for prevention of SAD

Bright white light therapy compared with no light therapy for prevention of SAD
Patient or population: All participants were known SAD patients who had been successfully treated with conventional light therapy in previous winters Settings: This was an outpatient field study. Participants chose when (between 6 am and 9 am) and where they would use the visors Intervention: bright white light therapy Comparison: no light therapy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	No light therapy	Light therapy
Incidence of SAD (SIGH‐SAD score ≥ 20) (follow‐up 26 weeks)	Low		RR 0.64 (0.30 to 1.38)	23 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	300 per 1000	192 per 1000 (90 to 414)
	Moderate
	500 per 1000	320 per 1000 (150 to 690)
	High
	600 per 1000	276 per 1000 (210 to 966)
Incidence of severe SAD (SIGH‐SAD‐SR (≥ 40)) (follow‐up 26 weeks)	Study population		RR 0.21 (0.03 to 1.75)	23 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	333 per 1000	70 per 1000 (10 to 583)
Overall discontinuation (follow‐up 26 weeks)	Study population		RR 2.22 (0.29 to 17.27)	28 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	100 per 1000	222 per 1000 (29 to 1000)
The basis for the assumed risk* (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI: Confidence interval; RCT: Randomised controlled trial; RR: Risk ratio; SIGH‐SAD‐SR: Structured Interview Guide for the Hamilton Depression Rating Scale‐Seasonal Affective Disorders self rating version
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Very low quality: We are very uncertain about the estimate
^aDowngraded 2 steps because of severe risk of bias due to non‐blinding and unclear randomisation process and allocation concealment; no intention‐to‐treat analysis was reported, outcomes were self rated, compliance throughout study duration was not checked and participant characteristics were not reported comprehensively ^bDowngraded 1 step because of small sample size (lack of power and random error could have influenced results)

Summary of findings for the main comparison. Bright white light therapy compared with no light therapy for prevention of SAD

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Summary of findings 2. Infrared light therapy compared with no light therapy for prevention of SAD

Infrared light therapy compared with no light therapy for prevention of SAD
Patient or population: All participants were known SAD patients who had been successfully treated with conventional light therapy in previous winters Settings: outpatient field study; participants chose when (between 6 am and 9 am) and where they would use the visors Intervention: infrared light therapy Comparison: no light therapy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	No light therapy	Infrared light therapy
Incidence of SAD (SIGH‐SAD score ≥ 20) (follow‐up 26 weeks)	Low		RR 0.50 (0.21 to 1.17)	24 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	300 per 1000	150 per 1000 (63 to 351)
	Moderate
	500 per 1000	250 per 1000 (105 to 585)
	High
	600 per 1000	300 per 1000 (126 to 702)
Incidence of severe SAD (SIGH‐SAD‐SR (≥ 40)) (follow‐up 26 weeks)	Study population		RR 0.20 (0.20 to 1.64)	24 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	333 per 1000	67 per 1000 (67 to 547)
Overall discontinuation (follow‐up 26 weeks)	Study population		RR 1.67 (0.20 to 13.98)	28 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	100 per 1000	167 per 1000 (20 to 1000)
The basis for the assumed risk* (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI: Confidence interval;RCT: Randomised controlled trial; RR: Risk ratio; SIGH‐SAD‐SR: Structured Interview Guide for the Hamilton Depression Rating Scale‐Seasonal Affective Disorders self rating version
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Very low quality: We are very uncertain about the estimate
^aDowngraded 2 steps because of severe risk of bias due to non‐blinding and unclear randomisation process and allocation concealment; no intention‐to‐treat analysis was reported, outcomes were self rated, compliance throughout study duration was not checked and participant characteristics were not reported comprehensively ^bDowngraded 1 step because of small sample size (lack of power and random error could have influenced results)

Summary of findings 2. Infrared light therapy compared with no light therapy for prevention of SAD

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Summary of findings 3. Light therapy compared with no light therapy for prevention of SAD

Light therapy (bright white or infrared) compared with no light therapy for prevention of SAD
Patient or population: All participants were known SAD patients who had been successfully treated with conventional light therapy in previous winters Settings: outpatient field study; participants chose when (between 6 am and 9 am) and where they would use the visors Intervention: light therapy Comparison: no light therapy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	No light therapy	Infrared light therapy
Incidence of SAD (SIGH‐SAD score ≥ 20) (follow‐up 26 weeks)	Low		RR 0.57 (0.30 to 1.10)	38 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	300 per 1000	171per 1000 (90 to 330)
	Moderate
	500 per 1000	285 per 1000 (150 to 550)
	High
	600 per 1000	342 per 1000 (180 to 660)
Incidence of severe SAD (SIGH‐SAD‐SR (≥ 40)) (follow‐up 26 weeks)	Study population		RR 0.21 (0.04 to 1.05)	38 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	333 per 1000	70 per 1000 (13 to 350)
Overall discontinuation (follow‐up 26 weeks)	Study population		RR 1.94 (0.27 to 14.01)	46 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	100 per 1000	194 per 1000 (27 to 1000)
The basis for the assumed risk* (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI: Confidence interval;RCT: Randomised controlled trial; RR: Risk ratio; SIGH‐SAD‐SR: Structured Interview Guide for the Hamilton Depression Rating Scale‐Seasonal Affective Disorders self rating version
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Very low quality: We are very uncertain about the estimate
^aDowngraded 2 steps because of severe risk of bias due to non‐blinding and unclear randomisation process and allocation concealment; no intention‐to‐treat analysis was reported, outcomes were self rated, compliance throughout study duration was not checked and participant characteristics were not reported comprehensively ^bDowngraded 1 step because of small sample size (lack of power and random error could have influenced results)

Summary of findings 3. Light therapy compared with no light therapy for prevention of SAD

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Summary of findings 4. Bright white light therapy compared with infrared light therapy for prevention of SAD

Bright white light therapy compared with infrared light therapy for prevention of SAD
Patient or population: All participants were known SAD patients who had been successfully treated with conventional light therapy in previous winters Settings: outpatient field study; participants chose when (between 6 am and 9 am) and where they would use the visors Intervention: bright white light therapy Comparison: infrared light therapy
Outcomes	Risk in both groups		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk in this treatment group	Risk in this treatment group
	Infrared light therapy	Bright white light therapy
Incidence of SAD (SIGH‐SAD score ≥ 20) (follow‐up 26 weeks)	Study population		RR 1.29 (0.50 to 3.28)	29 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	333 per 1000	357 per 1000
Incidence of severe SAD (SIGH‐SAD‐SR (≥ 40)) (follow‐up 26 weeks)	Study population		RR 1.07 (0.07 to 15.54)	29 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	67 per 1000	71 per 1000
Overall discontinuation (follow‐up 26 weeks)	Study population		RR 1.33 (0.35 to 5.13)	36 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
	167 per 1000	222 per 1000
CI: Confidence interval; RCT: Randomised controlled trial; RR: Risk ratio, SIGH‐SAD‐SR: Structured Interview Guide for the Hamilton Depression Rating Scale‐Seasonal Affective Disorders self rating version
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Very low quality: We are very uncertain about the estimate
^aDowngraded 2 steps because of severe risk of bias due to non‐blinding and unclear randomisation process and allocation concealment; no intention‐to‐treat analysis was reported, outcomes were self rated, compliance throughout study duration was not checked and participant characteristics were not reported comprehensively ^bDowngraded 1 step because of small sample size (lack of power and random error could have influenced results)

Summary of findings 4. Bright white light therapy compared with infrared light therapy for prevention of SAD

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Comparison 1. Bright light therapy vs no light therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Incidence of SAD (per protocol analysis) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Incidence of SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Incidence of SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Incidence of severe SAD (per protocol analysis) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Incidence of severe SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6 Incidence of severe SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

7 Overall rate of discontinuation Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 1. Bright light therapy vs no light therapy

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Comparison 2. Infrared light therapy vs no light therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Incidence of SAD (per protocol analysis) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Incidence of SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Incidence of SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Incidence of severe SAD (per protocol analysis) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Incidence of severe SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6 Incidence of severe SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

7 Overall rate of discontinuation Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 2. Infrared light therapy vs no light therapy

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Comparison 3. Light therapy (bright white and infrared) vs no light therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Incidence of SAD (per protocol analysis) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Incidence of SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 Incidence of SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 Incidence of severe SAD (per protocol analysis) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 Incidence of severe SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 Incidence of severe SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7 Overall discontinuation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 3. Light therapy (bright white and infrared) vs no light therapy

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Comparison 4. Bright light therapy vs infrared light therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Incidence of SAD (per protocol) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Incidence of SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Incidence of SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Incidence of severe SAD (per protocol) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Incidence of severe SAD (ITT, assuming no dropout was depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6 Incidence of severe SAD (ITT, assuming all dropouts were depressed) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

7 Overall discontinuation Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 4. Bright light therapy vs infrared light therapy

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