DEPRESSION AND ANXIETY 26:273–278 (2009)

Research Article
NARROW-BAND BLUE-LIGHT TREATMENT OF
SEASONAL AFFECTIVE DISORDER IN ADULTS AND THE
INFLUENCE OF ADDITIONAL NONSEASONAL SYMPTOMS
Robert E. Strong, D.O., Barrie K. Marchant, M.S., Frederick W. Reimherr, M.D., Erika Williams, M.S.W.,
Poonam Soni, M.D., and Ruth Mestas, CCRC

Background: Bright visible-spectrum light therapy has proven effective in the

treatment of seasonal affective disorder (SAD) and recent basic research suggests
that blue wavelengths 470 nm account for that effectiveness. To more
stringently test the importance of these wavelengths, bright red-light was used
for the placebo (control) condition. Methods: Thirty subjects meeting DSM-IV
criteria for SAD were randomized to narrow-band light-emitting diode panels
emitting blue- or red-light in this 3-week, parallel, double-blind trial. Twenty-
five subjects participated in an open-label blue-light follow-up. Subjects were
divided in a blinded, post hoc manner into two groups: SAD only and those
experiencing depression with seasonal intensification. The outcome was assessed
using Hamilton Depression Rating Scale–17 item version (HAMD-17) and the
Structured Interview Guide for the Hamilton Depression Rating Scale—SAD
version. Responders were defined by Clinical Global Impression—Improvement
scale. Results: HAMD-17 scores improved more under the blue-light condition
(51%) than under the red-light condition (32%) (P 5.05). Further, in the blue
arm 60% of subjects responded compared with 13% in the red arm (P 5.01).
During the open-label phase, subjects from both double-blind arms improved
over baseline. SAD alone patients responded numerically better to treatment
than those experiencing depression with seasonal intensification during both
treatment periods. Conclusions: Narrow bandwidth blue-light therapy proved
superior to red-light therapy. Blue-light therapy produced results similar to both
previous 10,000 lux visible-spectrum light studies and many medication studies.
The use of bright red panels supported claims that wavelengths of 470 nm
account for the documented effectiveness of light therapy. Depression and
Anxiety 26:273–278, 2009. r 2008 Wiley-Liss, Inc.

Key words: seasonal affective disorder; wavelength; light therapy; placebo-

controlled; randomized

Mood Disorders Clinic, Department of Psychiatry, University

of Utah Health Sciences Center, Salt Lake City, Utah
INTRODUCTION Correspondence to: Robert E. Strong, D.O., Mood Disorders

Most studies estimate that 4–6% of the general
population suffers from seasonal affective disorder
(SAD).[1] Conversely, Blazer et al.[2] found a 1%
prevalence of major or minor depression with a
seasonal pattern. The use of alternative diagnostic
procedures may explain these significantly different
estimates. Alternatively, pure SAD may be rare[3,4] or
the overlap between SAD and other depressive
Clinic, Department of Psychiatry, University of Utah Health
Sciences Center, Salt Lake City, Utah 84132.
E-mail: robert.strong@hsc.utah.edu
Received for publication 31 July 2008; Revised 18 September
2008; Accepted 19 September 2008
DOI 10.1002/da.20538
Published online 18 November 2008 in Wiley InterScience (www.
interscience.wiley.com).

r 2008 Wiley-Liss, Inc.

274 Strong et al.
disorders[5,6] may explain these differences. This
complication in diagnostic assessment may affect
research into SAD and light therapy by not separating
those patients experiencing incomplete summer remis-
sion.[7] Finally, the DSM-IV Criterion for Seasonal
Pattern Specifier does not preclude nonseasonal
depressive symptoms such as dysthymia.
Light therapy has been relegated to the edge of the
treatment paradigm[8] despite its documented efficacy.
A meta-analysis on its efficacy in treating SAD[9]
produced an effect size of .84. This lack of interest
may be partly attributable to limited training and
education.
Light therapy was intertwined with the original
description of SAD. Rosenthal et al.[10] reported on
patients with recurrent depression that developed in
fall or winter and remitted the following spring or
summer. He included preliminary findings indicating
that bright artificial light was effective in treating this
disorder and a hypothesis about the depressive effects
of melatonin.
Subsequently, intrinsically photosensitive retinal gan-
glion cells that project from the retina to the suprachias-
matic nucleus, intergeniculate leaflet and olivary pretectal
nucleus,[11] areas associated with circadian entrainment,
negative masking (suppressive effect of light on physio-
logical processes, which have a circadian rhythm),
regulation of sleep–wake states, the pupillary light reflex,
and melatonin suppression were identified. It is likely
that these intrinsically photosensitive retinal ganglion
cells give rise to the therapeutic effects of light. Although
it is clear that melanopsin-expressing ganglion cells in the
retina are intrinsically photosensitive, (especially by
wavelengths of 446–477 nm) Dacey et al.[12] found that
in rodents these cells can also be activated by rods and
cones. Thus, further evidence is needed to clarify
whether blue-wavelengths are necessary and/or sufficient
for the treatment effects of light therapy.
Glickman et al.[13] reported on a placebo-controlled
parallel trial of SAD comparing blue-light (468 nm at
398 lux) with dim red-light (654 nm at 23 lux). This
3-week study found a significant (P 5.02) positive
treatment effect with a medium effect size (d 5 .48).
However, a categorical measure of remission was not
significant. Response rates in the blue-light condition
were typical for visible-spectrum light therapy and also
similar to acute trials of antidepressants, except for a
quicker response time.
This protocol was designed to address three primary
questions.
* Was blue-light associated with a significant improve-
ment compared with red-light at visually similar
intensities?
* Did nonseasonal depressive symptoms (SAD only
versus depression with seasonal intensification)
impact the treatment effect?
* Was blue-light associated with significant adverse
events (AEs)?
Depression and Anxiety
MATERIALS AND METHODS
The 3-week, parallel, double-blind phase compared blue-light
(active treatment) with red-light (placebo condition) using weekly
visits. Subjects were instructed to sit about 50 cm in front of the light
panel and to glance at the light for a few seconds every minute for
45 min daily between 6:00 and 8:00 AM. Subjects were instructed not
to reveal the color of their panel. These instructions were provided by
staff not associated with assessments. Subjects asking about specific
colors were told that the importance of color remained uncertain and
that this study was designed to compare different wavelengths.
Diagnosis of SAD and assessing of outcome measures was carried out
by clinicians (R.E.S., F.W.R., and P.S.), with extensive research
experience.
Subjects who completed the double-blind phase could participate
in a 4-week open-label trial using blue-light with biweekly visits.
Instructions in this period were identical to those in the double-blind
period, except that subjects could deduce that the red-light had been
the placebo.
The University of Utah Institutional Review Board reviewed and
approved the study. The study was conducted in accordance with the
Declaration of Helsinki 1975 as revised in 2000.
SUBJECT SELECTION CRITERIA
Subjects with recurrent major depression according to the DSM-
IV with a seasonal pattern and a Structured Interview Guide for the
Hamilton Depression Rating Scale—SAD version (SIGH-SAD)
score Z20 were recruited. Subjects were required to have routine
sleeping patterns suitable for the treatment procedures, which
remained stable for the duration of the study. Subjects were required
to be in general good health, without any photosensitizing conditions
or the use of photosensitizing pharmacological agents. Subjects were
excluded if they had
(a) recently used light therapy;
(b) failed previous treatment with light therapy;
(c) abnormal thyroid-stimulating hormone (TSH) values;
(d) a co-occurring psychiatric disorder or medical condition that
could affect their mental status;
(e) ocular or dermatological health problems that might be affected
by light therapy.
ASSESSMENT MATERIALS
Hamilton Depression Rating Scale—17 item version (HAMD-17):
This depression scale was used at each visit.
Structured Interview Guide for the Hamilton Depression Rating Scale—
SAD version (SIGH-SAD): This structured interview version of the
HAMD-17 was developed for SAD and was used at each visit.
Clinical Global Impression—Improvement (CGI-I): This scale was
used at each visit following the screening interview.
LIGHT TREATMENT DEVICES
The light treatment units were designed and produced by the
sponsor of this study. The active unit was a 470 nm blue light-
emitting diode (LED) unit and the control unit was a 650 nm red
LED unit. Lux readings were blue panel 5 176 and red panel 5 201.
Photon density/cm2/s were blue panel 5 5.45 E14 and red pa-
nel 5 3.17 E14. The panels measured 4.500 by 300 . Although the
photon densities of the two panels differed, their visual intensities
were very similar.
Safety of the blue LED unit used in a previous study was
demonstrated by Glickman et al.[13], and an identical optical hazard
analysis[14] was performed on the blue panels used in this study.
 Research Article: Blue-Light Treatment of SAD 275

SEPARATION OF SAD DIAGNOSTIC TABLE 1. Baseline demographic measures and

CATEGORIES assessment of depressive symptoms
Although all subjects met criteria for the seasonal pattern, some Red-light Blue-light Totala
subjects had additional nonwinter symptoms. The diagnostic determi-
nation regarding SAD alone or a depressive illness with seasonal N 15 15 35
intensification of their depressive symptoms was made post hoc. A Ageb 39.579.9 51.1712.3 44.3712.60
clinician, who was blind to treatment, reviewed all patient charts. Items Male/femalec 2/13 5/10 9/26
suggesting that there were nonseasonal components to the SAD HAMD-17 19.775.1 20.373.7 20.074.4
diagnosis included: current, year-round use of antidepressant medica- SIGH-SAD total 34.175.9 34.175.6 34.175.6
tion; history of past antidepressant treatment in nonwinter seasons; or SAD alone 11 (73%) 8 (53%) 20 (61%)d
depressive symptoms during summer months. Depression with seasonal 4 (27%) 7 (47%) 13 (39%)
intensification
DATA ANALYSIS AND STATISTICAL a
All randomized and nonrandomized subjects meeting admission
PROCEDURES criteria.
b
The primary objective of comparing the efficacy of blue- versus t 5 2.31, df 5 28, P 5.03.
c 2
red-light was accomplished by comparing improvement in HAMD- X 5 1.70, df 5 1, P 5.19.
d
17 scores using a last observation carried forward (LOCF) format and Two nonrandomized patients had insufficient data to be categorized
using a repeated measures ANOVA procedure with treatment (red accurately regarding the two SAD subgroups.
versus blue) as the primary predictor variable and controlling for
three other between-subjects variables: gender, age, and SAD
diagnostic category. Improvement across time was a within-subjects TABLE 2. Improvement in depressive symptoms during
factor. A similar model was used to assess improvement in the SIGH- the double-blind phase as a function of treatment
SAD scores. As gender and age proved to be nonsignificant, both
analyses were repeated and are reported without them. Categorical Red-light Blue-light P-valuea
improvement was analyzed using Fisher’s exact test.
Improvement in continuous measures of depression at the open- N 15 15
label termination visit was accomplished (LOCF) using a repeated Categorical improvement: N (%) improved
measures ANOVA procedure comparing the final open-label evalua- CGI-Ir2 2 (13%) 9 (60%) .01
tion with the baseline assessment including the two SAD diagnostic HAMD-17 (50% improvement) 2 (13%) 8 (15%) .025
categories as a between-subjects variable. Categorical improvement SIGH-SAD (50% improvement) 2 (13%) 6 (40%) .107
was analyzed using Fisher’s exact test. The two treatment groups Decline in HAM-D scores: mean7SD (percent improvement over
(previously blue- or red-light) were assessed separately for change baseline)
from double-blind endpoint to open-label endpoint using paired SIGH-SAD total 10.2710.7 15.779.6 .15b
t-tests for continuous variables and the Fisher exact test for (21%) (40%)
categorical variables. HAMD-17 6.073.9 10.175.3 .05c
Side effects were assessed for all subjects following randomization. (32%) (51%)
Both specific side effects and open-ended questioning were used. The SAD alone 5.974.2 11.675.5 .08
safety analysis set was reported based on the treatment received. (32%) (61%)
Analysis was completed using the SPSS version 14 statistical Seasonal intensification of 6.373.4 8.375.0 .70
package. depression (30%) (40%)
a
P-values were calculated (LOCF) using a repeated measures
RESULTS ANOVA procedure for continuous variables and the Fisher exact
test for categorical variables.
Thirty-five subjects met admission criteria for the b
Treatment had a nonsignificant effect on SIGH-SAD scores
study. Of these, 5 were not randomized and provided (F1,26 5 2.19, P 5.15).
c
no outcome data and 30 furnished outcome data. The Treatment had a significant main effect on HAMD-17 scores
patients in the blue-light group were significantly older (F1,26 5 4.52, P 5.043). Diagnosis (SAD alone versus seasonal
than the red-light group (P 5.03) (see Table 1). intensification of depression) interacted with treatment at a
nonsignificant level (P 5.321).
HAMD-17 and SIGH-SAD scores were not statisti-
cally different. Although the blue-light sample had
more males, this difference was not statistically
significant. A substantial minority of subjects (39%)
had seasonal intensification of major depressive dis- shown in Table 2 and Figure 1, on the HAMD-17,
order. More of these were randomized to the blue-light subjects improved an average of 6.073.9 (32%) points
(n 5 7) than the red-light (n 5 4) treatment arm. in the red-light condition compared with 10.175.3
(51%) in the blue-light condition (F1,26 5 4.52,
P 5.043). As shown in Table 2 and Figure 2, on the
DOUBLE-BLIND OUTCOME SIGH-SAD total, subjects improved an average of
Table 2 shows improvement for the 30 randomized 10.2710.7 (21%) points in the red-light condition
subjects. The treatment effect was statistically signifi- and 15.779.6 (40%) in the blue-light condition
cant for the HAMD-17, but not the SIGH-SAD. As (F1,26 5 2.19, P 5.15).
Depression and Anxiety
276 Strong et al.

TABLE 3. Open-label outcomes compared to baseline

and double-blind scores for 25 subjects entering the
open-label phase. Data are presented using an LOCF
format within each phase

Double- Open-
Baseline blind label P-valuea

Red-light group N 5 13
HAMD-17 19.475.3 13.275.7 6.577.9 .022
SIGH-SAD total 33.676.1 22.879.3 10.2710.5 .003
CGI-Ir2 na 2 (15%) 11 (85%) .001
Blue-light group N 5 12
Figure 1. Average HAMD-17 scores at each visit for both HAMD-17 20.674.0 9.876.7 8.077.1 ns
treatment groups. [Color figure can be viewed in the online SIGH-SAD total 34.276.1 17.5710.2 12.379.9 ns
issue, which is available at www.interscience.wiley.com.] CGI-Ir2 na 8 (67%) 10 (83%) ns
a
P-values compare open-label with double-blind scores (LOCF).
Continuous data were assessed using paired t-tests and categorical
data were assessed using the Fisher exact test.

17 scores (F1,21 5 120.6, Po.001) and 73% on SIGH-

Figure 2. Average SIGH-SAD scores at each visit for both
treatment groups. [Color figure can be viewed in the online
issue, which is available at www.interscience.wiley.com.]
Only two (13%) subjects were ‘‘much’’ or ‘‘very
much’’ improved on the CGI-I under the red-light
condition versus nine (60%) subjects under the blue-
light condition (Fisher’s exact test 5 .01).
Differences between SAD alone and depression
with seasonal intensification. There were 19 subjects
with pure SAD. The 8 subjects in the blue-light
arm improved 61% on the HAMD-17 compared
with a 32% improvement for the 11 subjects
in the red-light arm (P 5.08). There were 11
subjects experiencing depression with seasonal intensi-
fication. The seven subjects in the blue-light arm
improved 40% on the HAMD-17 compared with a
30% improvement for the four subjects in the red-light
arm (P 5.70).
OPEN-LABEL OUTCOME
Of the 15 subjects randomized to red-light, 2
dropped out during the double-blind period. Thus,
13 entered the open-label phase. Of the 15 subjects
randomized to blue-light, 1 dropped out during the
double-blind phase and 2 more chose not to partici-
pate. Thus, 12 entered the open-label phase.
Change from baseline to endpoint was significant for
these 25 subjects. Subjects improved 64% on HAMD-
Depression and Anxiety
SAD scores (F1,21 5 112.7, Po.001).
As shown in Table 3, subjects from the red-light
group showed statistically significant improvement
during the open-label period in all measures. In
contrast, subjects from the blue-light group showed
only nonsignificant additional gains during the open-
label period. Thus, the two groups had equivalent
levels of depression at the end of the open-label phase.
(The five subjects who did not enter the open-label
period were excluded from this table.)
Differences between SAD alone and depression with
seasonal intensification. Both subjects with SAD
alone and depression with seasonal intensification
showed statistically significant improvement by the
end of the open-label phase. On the HAMD-17 the 16
subjects with SAD alone improved 71% over baseline
(P 5.001), whereas the 9 subjects experiencing depres-
sion with seasonal intensification improved 56%
(P 5.005) (LOCF). Similarly, 88% of subjects with
SAD alone met CGI-I criteria for improvement
compared with 67% of subjects experiencing depres-
sion with seasonal intensification for a nonstatistical
difference between groups.
AEs AND SIDE EFFECTS
Blue-light therapy was essentially equivalent to red-
light therapy in the incidence of AEs. As shown in
Table 4, AEs were limited in number and similar to
10,000 lux light studies (fluorescent lamps that appear
white). All AEs were in the mild-to-moderate range
and only one subject left the study as a result.
TIME OF YEAR
The average date for the screening visit was January
25, 2006. The average date for ending the double-blind
phase was February 22, 2008, and the average date for
ending the open-label phase was March 22, 2008.
 Research Article: Blue-Light Treatment of SAD
TABLE 4. The number of adverse events and side
effects under both light conditions
Red-light Blue-light
Headache 1 5
Sleep disturbance 1 2
Eye irritation 0 2
Upper respiratory infection 4 1
Lightheaded/dizzy 0 1
Sunburn 0 1
Photosensitivity 0 1
Nausea 0 1
Odd dreams 0 1
Memory problems 0 1
Dysphoria 0 1
Nightmares 1 0
Neck pain 1 0
DISCUSSION
These data support the hypothesis that light therapy
using narrow-band LED panels emitting wavelengths
of 470 nm is effective in the treatment of SAD. This
trial attempted to address several concerns in previous
trials. First, the dimness of past red-panels may have
made them recognizable as placebo. Second, therapeu-
tic benefits of red-light may have been limited as much
by the dimness of the light source as by the wavelength.
Both concerns were addressed by the use of these
brighter red-light panels. Our patients treated with
bright-red panels had a response very similar to the
response rates reported in the past studies of dim-red-
light panels.
As in previous trials, the 470 nm wavelength proved
superior to the 650 nm wavelength in treating SAD.
This treatment response was observed in the double-
blind controlled phase of the trial and continued in the
open-label phase. Although both groups improved
during the double-blind phase, the blue-light group
improved significantly more than the red-light group.
The blue-light group had a 60% response rate using
CGI-I criteria, whereas the placebo red-light group
had only a 13% response rate.
Regardless of treatment status during the first phase,
subjects were much improved at the end of the open-
label period with average HAMD-17 scores of 6.577.9
for the sample previously on red-light therapy and
8.077.1 for the sample previously on blue-light
therapy. The fact that the red-light group had
improved significantly to a point of equivalency with
the blue-light group gives some additional support for
the efficacy of blue-light treatment.
Given that subjects were enrolled in January and
February improvement could be attributed to the
change in seasons rather than treatment. However, no
evidence for this was observed. (Nineteen patients were
enrolled in January and eleven were enrolled in
February.) If there was improvement due to a change
in season, there should have been a higher red-light
277
response rate for subjects enrolled during February.
This did not happen. Two of nine red-light subjects
who were enrolled in January met CGI-I criteria for
treatment response, whereas none of the six that were
enrolled in February responded.
Almost 40% of the patients in this study showed a
pattern of depression with seasonal intensification, a factor
deserving further exploration despite the limited numbers.
During the controlled phase, SAD alone subjects experi-
enced a treatment effect on the HAMD-17, which
approached significance, whereas those experiencing
depression with seasonal intensification did not. Further,
the SAD alone subjects had a numerically higher open-
label treatment response rate than those experiencing
depression with seasonal intensification. One potential
explanation for these numerical differences is that those
experiencing depression with seasonal intensification are
suffering from more than one disease process (dual
vulnerability hypothesis), thus requiring treatment with
antidepressant medication. This explanation would also
suggest that some patients diagnosed with a depressive
disorder, who only partly respond to treatment with
antidepressant medication, might suffer from a comorbid
form of SAD and require light therapy for full response.
The number and severity of AEs and side effects was
minimal and similar to earlier studies using white
fluorescent lamps.[15, 16] The severity of these symptoms
was in the mild-to-moderate range. Most problems
remitted spontaneously and only one subject discontinued
treatment because of them (ocular photosensitivity).
CONCLUSION
In conclusion, blue-light therapy using narrow-band
LED panels appeared to be an effective treatment for
SAD. It outperformed bright red-light therapy and
produced results similar to both 10,000 lux bright light
studies and medication studies. The use of bright red
narrow-band LED panels provided a more credible
control condition than dim red panels. The results support
biological studies implicating photosensitive retinal gang-
lion cells and melatonin suppression in the treatment of
seasonal affective disorder. Finally, our data suggest that:
(1) nonseasonal depressive symptoms might be associated
with a lower response to light therapy and (2) seasonal
factors might play a role in the incomplete recovery
frequently seen in patients with major depression.
Acknowledgments. The original clinical trial was
sponsored by Apollo Light Systems. This analysis was
performed in cooperation with, but not funded by,
Apollo Light Systems. This article was presented in
part as a poster at the 2007 Annual Meeting of the
Society of Biological Psychiatry, San Diego, CA.
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