Bright Light Therapy for Schizoaffective Disorder

Mr. A, a 50-year-old man, was diagnosed with schizoaffective disorder with recurring depressive episodes in winter. His first episode was in autumn and included symptoms of depression as well as perceptual disturbances, including auditory and visual hallucinations. Subsequently, he experienced depressive symptoms almost every winter. Although he worked for several years in an isolated setting and experienced other periods of productive activity, his course of illness was remarkable for social withdrawal, avolition, consistently disorganized thoughts independent of mood, and highly idiosyncratic—sometimes bizarre—ideation. He intermittently abused marijuana and alcohol. During euthymic, substance-free periods, he experienced months-long periods of hallucinations. Trials with fluoxetine were unsuccessful in treating his depressive episodes. Haloperidol worsened his mood symptoms without improving his withdrawal or avolition. In autumn his seasonal depression was treated with methylphenidate, which proved more effective than other medications. Unfortunately, this psychostimulant exacerbated his thought disorder. In the spring, as his mood improved, Mr. A and his clinician agreed that he would remain medication free throughout the summer.

Mr. A appeared for treatment in an unmedicated condition in the autumn with new onset of a depressive episode and loss of energy, interest, and motivation resulting in functional and occupational impairment. His score on the Hamilton Depression Rating Scale, Seasonal Affective Disorders Version (3), was 27 (score of 21 on the 21-item Hamilton depression scale and score of 6 for atypical symptoms), which is consistent with moderate depression (4). He was not experiencing perceptual disturbances but displayed tangentiality, thought derailment, and idiosyncratic thought content. His hygiene and grooming were poor to fair.

In consideration of his pattern of seasonal depression, an empirical home trial of bright light therapy with no additional medication was attempted. He was instructed to use a 10,000-lux SunRay light box (SunBox Company, Gaithersburg, Md.) for daily treatment from 7:00 a.m. to 7:30 a.m. and to glance directly at the unit approximately once every minute. Within 1 week Mr. A’s Hamilton depression scale score decreased from 21 to 9, and his atypical depression rating decreased from 6 to 1. Daily treatment with the light box was then increased to 45 minutes, resulting in no adverse effects. Within 1 week Mr. A’s Hamilton depression scale score had further decreased to 3; his atypical depression rating remained at 1. His functioning had improved in all dimensions, including grooming and hygiene and the ability to maintain his household and care for his family. Loose associations of speech and idiosyncratic thought remained. A low dose of olanzapine was later added, since his thought disorder continued unabated.