Light Therapy in Post-Traumatic Stress Disorder: A Systematic Review of Interventional Studies
Abstract
:1. Introduction
1.1. Rationale
1.2. Objectives
2. Methods
2.1. Eligibility Criteria
2.2. Information Sources and Search Strategy
2.3. Selection Process
2.4. Data Extraction and Collected Data
2.5. Study Risk of Bias Assessment
2.6. Synthesis Methods
3. Results
3.1. Study Selection
3.2. Study Characteristics
3.3. Risk of Bias in Studies
3.4. Results of Syntheses
4. Discussion
4.1. General Interpretation in the Context of Other Evidence
4.2. Strengths and Limitations of the Review
4.3. Implications of the Results for Practice, Policy, and Future Research
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Acknowledgments
Conflicts of Interest
References
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Inclusion Criteria | Exclusion Criteria |
---|---|
> Interventional studies on light therapy > Studies targeting patients with posttraumatic stress disorder > Studies assessing mental health (sleep–wake cycles, mood, anxiety, post-traumatic symptomatology, and extinction memory), neuroanatomical, or neurofunctional outcomes | > Studies on paediatric populations > Studies on animal models > Article types such as case reports, letters to the editor, comments, and reviews > Duplicated articles (especially the least recent duplicate) > Full-text unavailability > Studies in other languages other than English of French |
Study | Location and Period | Design | Population (with PTSD Screening Tool) | Interventions in Each Arm [LT Group and Control Group if Applicable] | Sample Size and Male/Female Ratio | Mean Age (SD) and Age Range |
---|---|---|---|---|---|---|
Elliott et al. 2022 [32] | United States of America, August 2017 to August 2018 | Uncontrolled Clinical Trial Open-label | Veterans with history of TBI, and having comorbid PTSD [assessed with the PTSD checklist for DSM-5 (PCL-5)] | Morning bright light therapy = lightbox (~10,000 lux at the eye) for 60 min every morning for 4 weeks (UCT) | 18 and NR | NR |
Killgore et al. 2022 [33] | United States of America, NR. | Randomized Controlled Trial Double-blind | Individuals meeting DSM-5 criteria for PTSD | Blue-light exposure treatment (BLT, peaking at λ = 469 nm, at 214 lux) versus a matched amber light treatment (ALT, peaking at λ = 578 nm, at 188 lux) [daily for 30 min over 6 weeks] | 76 (39 on BLT versus 37 on ALT) and 25/51 (14/25 versus 11/26) | 31.4 (8.8), from 20 to 49 years of age |
Vanuk et al. 2022 [38] | United States of America, NR. | Randomized Controlled Trial Double-blind | Individuals with PTSD undergoing a well-validated fear conditioning/extinction protocol with assignment to interventions | Morning BLUE (BLT, peaking at λ = 469 nm, at 214 lux) or placebo AMBER (ALT, peaking at λ = 578 nm, at 188 lux) light therapy daily for 30 min over 6 weeks | 82 (43 on BLT versus 39 on ALT) and 14/29 versus 12/27 | 31.7 (8.8) for BLT versus 30.2 (8.7) for ALT |
Youngstedt et al. 2022 [39] | United States of America, NR. | Randomized Controlled Trial Single-blind | Veterans with PTSD attributable to combat in Afghanistan and/or Iraq (DSM-IV) | 4 weeks of daily morning bright light treatment (10,000 lux for 30 min/day) or a control treatment (inactivated negative ion generator) | 69 (34 for bright light and 35 for the control treatment) | NR |
Zalta et al. 2019 [40] | United States of America, NR | Randomized Controlled Trial | Individuals with probable PTSD established using a self-report measure (however, participants had to have a PTSD Checklist for DSM-5 score > 33) | Active Re-timer® † (n = 9) [(~500 nm, 500 lux)] versus placebo Re-timer® dimmed with neutral density filters (n = 6), during one hour in the morning, for 4 weeks | 15 (9 on the active treatment versus 6 on the placebo treatment), 7/8 (5/9 versus 2/6) | 44.9 (11.8) [40.8 (9.3) versus 51 (13.3)] |
Study | D1: ROB Arising from the Randomization Process | D2a: ROB Due to Deviations from the Intended Interventions/Effect of Assignment to Intervention | D2b: ROB Due to Deviations from the Intended Interventions/Effect of Adherence to Intervention | D3: ROB Due to Missing Outcome Data | D4: ROB in Measurement of the Outcome | D5: ROB in Selection of the Reported Result | Overall ROB |
---|---|---|---|---|---|---|---|
Killgore et al. 2022 [33] | Low | Low | Low | Low | Low | Low | Low |
Vanuk et al. 2022 [38] | Low | Some concern | Low | Low | Low | Low | Some concern |
Youngstedt et al. 2022 [39] | Low | Some concern | Low | Low | Low | Low | Some concern |
Zalta et al. 2019 [40] | Low | Low | Low | Low | Low | Low | Low |
Study | Outcomes of Interest and Risk of Bias | Effects on Sleep Parameters | Effects on Other Mental Health Parameters |
---|---|---|---|
Elliott et al. 2022 [32] | > Sleep quality (with the ISI), TBI (with the NSI), PTSD (with the PCL-5), Mood (with the PHQ-9), Pain, Quality of life, sleep actigraphy parameters [total sleep time (TST), time in bed (TIB), sleep onset latency (SOL), sleep efficiency (SE), wake after sleep onset (WASO), total activity, average activity/epoch, and number of nocturnal awakenings] > Risk of bias = Low | > Subjects with comorbid PTSD had higher pre-intervention ISI scores: ISI with PTSD = 17.1±5.3, versus ISI without PTSD = 11.9±5.5. > Subjects with comorbid PTSD had a greater percent change post intervention: 15.1±16.9% with PTSD, versus 8.7±13.8% without PTSD. This corresponded to post-intervention ISI scores of 12.9±4.5 (TBI with PTSD), versus 9.5±4.6 (TBI without PTSD). > Considering a 4-point decrease in ISI score to define response to light therapy, subjects with comorbid PTSD had 5.76 times the odds (CI: 1.18–28.28; p = 0.041) of showing a response to light therapy compared to subjects without PTSD. > Based on these raw scores, subjects with PTSD shifted from “moderate” insomnia to “mild” insomnia, while those without PTSD remained in the “mild” category. | > Improvement of PTSD symptom severity. > No other specific results for patients with TBI and PTSD, regarding the other mental health parameters. > There were no documented important harms or unintended effects during the study. |
Killgore et al. 2022 [33] | > Sleep outcomes assessed with questionnaires [Pittsburgh Sleep Quality Index (PSQI), Disturbing Dreams and Nightmares Severity Index (DDNSI), Insomnia Severity Index (ISI)] or by wrist actigraphy [time in bed (TIB), total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE)] > Neuroimaging scans / neuroimaging data [analysed using the Computational Anatomy Toolbox (CAT12) and Voxel-Based Morphometry (VBM) modules] > Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) > Risk of bias = Low | > The BLT condition produced significant increases in total time in bed (per-protocol and intention-to-treat analyses) and total sleep time from actigraphy compared to the ALT condition (only per-protocol analysis). > WASO and SE declined significantly for the ALT group but did not change for the BLT group (per-protocol and intention-to-treat analyses). > Light therapy did not significantly influence changes in PSQI total scores, in DDNSI scores, in ISI Total scores, or in SOL. | > BLT led to a significant increase in GMV within the left amygdala, compared to ALT, but did not affect hypothesized medial prefrontal regions (the expected increase in GMV within the medial prefrontal cortex was not found). > Within-group correlations showed that improvements in sleep quality and nightmare severity were correlated with increases in left amygdala volume over the course of treatment for the BLT group but not the ALT group. |
Vanuk et al. 2022 [38] | > Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), Insomnia Severity Index (ISI), Disturbing Dreams and Nightmares Severity Index (DDNSI) > Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) > Skin conductance response (during fear conditioning, extinction learning), electrocardiogram, brain activation through functional magnetic resonance imaging (fMRI), anatomical neuroimaging data > Risk of bias = Some concern | > Individuals in both the ALT and BLT reported improved sleep as measured by lower PSQI scores (indicating fewer symptoms of disrupted sleep) and higher FOSQ scores. > Both groups also reported lower levels of insomnia severity as measured by the ISI and nightmares as measured by the DDNSI. > Changes in daytime sleepiness as measured by the ESS were not significant. To summarize, subjective sleep tended to improve between baseline and post-treatment. However, this improvement was not qualified by significant interaction effects and both groups tended to show similar improvements. | > With LT, there was a strong effect of time on PTSD severity, beta = −0.62, 95% CI [−0.80, −0.44], t(154) = −6.67, p < 0.001, as assessed by the CAPS-5. There was a decrease in PTSD symptoms, as assessed by the PCL-5, beta = −0.38, 95% CI [−0.52, −0.24], t(155) = −5.24, p < 0.001. Nevertheless, both groups improved in PTSD symptoms and severity (no significant differences between the active and the placebo group). > Participants receiving BLT also sustained retention of the extinction memory, while those in the placebo amber light treatment group showed impairment, characterized by the restoration of the extinguished fear response after 6 weeks. > Daily BLUE-wavelength morning light exposure was associated with greater retention of extinction learning in patients with PTSD when compared to ALT. > Participants in the ALT also demonstrated greater reactivity in the left insula when viewing the previously extinguished fear-conditioned stimuli in a novel context. > BLT resulted in a significant decrease in activation responses within the left insular cortex relative to ALT. In all, BLT promotes the consolidation of extinction memories via improved sleep. > Sex differences in extinction recall. |
Youngstedt et al. 2022 [39] | > Pittsburgh Sleep Quality Index (PSQI) and PSQI Addendum for PTSD (PSQIADD). > Sleep and the circadian rhythm parameters assessed through wrist actigraphy. > Clinician-Assessed PTSD Scale (CAPS), Clinical Global Impressions Scale (CGI), Hamilton Depression Scale, PTSD Checklist-Military (PCL-M) with a self-rating, Hamilton Depression Scale, Hamilton Atypical Symptoms, Clinical Global Impressions (CGI) scale. > Self-reported scales of state anxiety [State-Trait Anxiety Inventory (STAI Form Y-2)], depression [Beck Depression Inventory (BDI)], and side effects [Systematic Assessment for Treatment Emergent Effects (SAFTEE) side effect questionnaire] > Risk of bias = Some concern | > Changes in actigraphic estimates of sleep (TST, WASO, and SE) and changes in PSQI and PSQI Addendum items did not differ significantly between treatments. > Of note, the slope differences [95% confidence interval] (control vs. bright light) for PSQI, PSQI Addendum, TST, WASO, and SE, were, respectively, −0.2 [−0.6; 0.2], −0.2 [−0.6; 0.2], 3.4 [−6.4; 13.2], 0.2 [ −0.5; 0.9], and 1.4 [−1.0; 3.7]. | > Compared with the control treatment, bright light elicited significantly greater improvements in the CAPS (Intergroup difference in before—after variation = −9.52 with a 95% confidence interval from −18.48 to −0.55) and the CGI. There was a significantly better CGI-IM score following the bright light treatment compared with the control treatment (coefficient: −0.57, P=0.034). > Improvement. The bright light also elicited a significantly greater rate of treatment response (reduction ≥33%) for the CAPS (44.1% vs. 8.6%) and PCL-M (33% vs. 6%), but no participant had remission from PTSD. > The bright light elicited a phase advance of the activity acrophase, whereas the control treatment resulted in a phase delay, with a statistically significant difference. > Changes in depression (Hamilton scales) and anxiety did not differ between treatments. Improvement in CAPS was significantly correlated with a phase advance of the circadian rhythm of wrist activity. > There was a lack of significant treatment difference in PCL-M, BDI, STAI, and PSQI at 1 month, 4 months, and 8 months (data, respectively, obtained from 29, 24, and 16 participants). > Regarding safety, the number of symptoms endorsed and number of symptoms pertaining to the head, eyes, and mania/agitation decreased following both treatments. There was no significant treatment effect for any of these metrics. |
Zalta et al. 2019 [40] | > PCL-5, PHQ-9, PSQI. > Minimal clinically important difference (MCID) for the DSM-IV version of the PTSD checklist. This MCID is defined as a 10-point improvement. > Objective actigraphy estimates of sleep onset time, wake time, total sleep time, and wake after sleep onset. > Risk of bias = Low | Active group participants reported greater improvements in subjective sleep quality from pre- to post-treatment than placebo participants. Also, they saw a greater advance in wake time relative to placebo participants, a decrease in TST from pre- to post-treatment of approximately 36 min, and a decrease in WASO from pre- to post-treatment (whereas placebo participants showed a slight increase in WASO from pre- to post-treatment). However, there were no statistical differences regarding all sleep parameters. | > Those in the active group were more likely to achieve a minimal clinically important change in PTSD and depression symptoms than those in the placebo group. > Participants in the active group also had larger reductions in PTSD and depression symptoms from pre- to post-treatment than those in the placebo group (d = 0.94 and 0.74, respectively). > The treatment was also well tolerated by participants. |
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Millot, F.; Endomba, F.T.; Forestier, N. Light Therapy in Post-Traumatic Stress Disorder: A Systematic Review of Interventional Studies. J. Clin. Med. 2024, 13, 3926. https://doi.org/10.3390/jcm13133926
Millot F, Endomba FT, Forestier N. Light Therapy in Post-Traumatic Stress Disorder: A Systematic Review of Interventional Studies. Journal of Clinical Medicine. 2024; 13(13):3926. https://doi.org/10.3390/jcm13133926
Chicago/Turabian StyleMillot, Florian, Francky Teddy Endomba, and Nathalie Forestier. 2024. "Light Therapy in Post-Traumatic Stress Disorder: A Systematic Review of Interventional Studies" Journal of Clinical Medicine 13, no. 13: 3926. https://doi.org/10.3390/jcm13133926
APA StyleMillot, F., Endomba, F. T., & Forestier, N. (2024). Light Therapy in Post-Traumatic Stress Disorder: A Systematic Review of Interventional Studies. Journal of Clinical Medicine, 13(13), 3926. https://doi.org/10.3390/jcm13133926