Administration of phototherapy

Since the best established indication for phototherapy is seasonal affective disorder, the following account will describe the use of bright-light treatment in winter depression. One of the major practical difficulties in phototherapy is the time needed to administer the treatment. For this reason a 10 000-lux light box may be preferred because the daily duration of therapy can be reduced to between 30 and 45 min. It seems likely that cool-white light and full-spectrum light have equivalent clinical efficacy, but because cool-white light is free of ultraviolet light it is theoretically safer and should be preferred. ^J.'

Some studies suggest that the bright-light treatment of winter depression is most effective when administered in the early morning. However, treatments given at other times of day, including the evening, may prove beneficial and can be more convenient for some patients.(6) In an initial trial, therefore, it is best to recommend early-morning treatment, but to advise the patient that the exact timing of therapy can eventually represent a balance of therapeutic efficacy and practical convenience. Treatment should not be given late in the evening because of the possibility of sleep disruption.

Early-morning phototherapy should start within a few minutes of awakening. Subjects should allow an initial treatment of 30-min duration with a 10 000-lux light box or 2 h with 2500-lux equipment. They should seat themselves about 30 to 40 cm away from the light-box screen. They should not gaze at the screen directly, but face it at an angle of about 45° and glance across it once or twice each minute.

The antidepressant effect of light treatment can appear within a few days, but in controlled trials longer periods (up to 3 weeks) can be needed before the therapeutic effects of bright light exceed those of placebo treatment. As noted above mild side-effects are common in the early stages of treatment, but these usually settle without specific intervention. If they are persistent and troublesome the patient can sit a little further away from the light source or reduce the duration of exposure. Exposure should also be reduced if elevated mood occurs.

Once a therapeutic response has occurred it is necessary to continue phototherapy up to the usual time of natural remission, otherwise relapse will occur. It may be possible, however, to lower the daily duration of treatment. Phototherapy may be also be started in advance of the anticipated episode of depression as this appears to have a prophylactic effect. (12>

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