By Azi Ghaffari, Ph.D. and Courtney Cornick, Ph.D.
Health psychologists who work in inpatient medical settings may know that poor or irregular sleep at night and subsequent low energy during the day, as well as low mood secondary to prolonged hospitalization, are common problems for hospitalized patients. These problems can be easier to resolve in patients who have short admissions, but more difficult to address in patients who are admitted for longer periods. Moreover, depression and insomnia may sometimes result in patients not being able to participate in daily cares, treatment, or rehabilitation therapies.
There are a variety of modalities (e.g., pharmacotherapy and Cognitive Behavioral Therapy; CBT) used to improve sleep and well-being of patients who are hospitalized. As health psychologists, we continue to explore more ways to assist our patients to achieve better outcomes during hospitalization in addition to optimally managing their mood and sleep. Numerous studies have explored the effectiveness of bright light therapy (BLT) to strengthen the circadian rhythm, improve sleep, and treat mood disorders (Golden et al., 2005). For example, BLT as a treatment for seasonal affective disorder has been well-established, and recent research has indicated BLT as a monotherapy and BLT in combination with fluoxetine as an effective for the treatment of nonseasonal major depressive disorder (MDD; Lam et al., 2016). Additionally, BLT is an effective intervention for the treatment of insomnia (Termen, 2007). However, few studies have investigated the degree to which BLT may predict improvement in sleep and/or mood in an inpatient setting. Furthermore, no studies have examined the impact BLT may have on the mood and sleep quality of individuals with spinal cord injury/disorders (SCI/D).
We are health psychologists who work primarily with inpatients with spinal cord injury/disorders (e.g., SCI, MS, ALS, and Guillian-Barre Syndrome), a majority of whom are older adults. Our patients can be admitted for months at a time, during which time they can have complaints including being in an unfamiliar environment; lack of comfortable sleeping arrangements; interruptions by staff for medical care; and disruptive noises and lights; all of which can contribute to poor sleep. Furthermore, individuals with SCI/D have several conditions common to SCI/D (e.g., decreased activity levels, pressure ulcer prevention routines, more time spent in bed, decreased levels of melatonin, prevalence of depressive symptoms, and changes in the body’s temperature regulation system and circadian clock), that can make sleep difficulties prevalent in this population (Giannoccaro et al., 2013).
Through a Human Centered Design (HCD) approach, we identified a need to address the problems with sleep and mood in our inpatient medical setting. With funding from the VA innovators grant program, we implemented a Performance Improvement (PI) project to improve sleep and mood for hospitalized patients in our SCI/D center. As a standard of care in our setting, all inpatients on our unit are given the Patient Health Questionnaire (PHQ-9 – a 9-item screen for depression) and the Insomnia Severity Index (ISI – a 7-item screen for insomnia) as part of their initial assessment. We invited patients with a PHQ-9≥10 and an ISI≥15 to use BLT (7,500 lux) for 30 minutes every morning. After four weeks, we conducted a follow-up that included re-administration of both the PHQ-9 and ISI. It should be noted that a light box of 7,500 lux was selected rather than 10,000 lux (which is cited in some previous findings) because research suggests using 7,500 lux for an older adult patient population to avoid side effects of eye sensitivity that are associated with higher light exposure (Sloane, Figueiro, & Cohen, 2008).
Our preliminary findings indicate a significant improvement in both mood and quality of sleep when patients utilized BLT. These domains may interact with treatment processes, and could also be viable treatment targets. We are looking forward to presenting this project in more detail at the APA Conference in August, and plan to initiate more research into this area. We have been thrilled with the findings thus far in our inpatient medical setting, and encourage other health psychologists in inpatient environments to consider BLT as an intervention when working with patients with prolonged hospitalizations.
Giannoccaro, M. P., Moghadam, K. K., Pizzza, F., Boriani, S., Maradli, N. M., Avoni, P., …Plazzi, G. (2013). Sleep disorders in patients with spinal cord injury. Sleep Medicine Review, 17, 399-409. doi: 10.1016/j.smrv.2012.12.005.
Golden, R. N., Gaynes, B. N., Ekstrom, R. D., Hamer, R. M., Jacobsen, F. M., Suppes, T., …Nemeroff, C. B. (2005). The efficacy of light therapy in the treatment of mood disorders: A Review and Meta-Analysis of the Evidence. American Journal of Psychiatry, 16, 656-662.
Lam, R. W., Levitt, A. J., Levitan, R. D., Michalak, E. E., Cheung, A. H., Morehouse, R., … & Tam, E. M. (2016). Efficacy of bright light treatment, fluoxetine, and the combination in patients with nonseasonal major depressive disorder: a randomized clinical trial. JAMA psychiatry, 73, 56-63. doi:10.1001/jamapsychiatry.2015.2235
Sloane, P. D., Figueiro, M., & Cohen, L. (2008). Light as therapy for sleep disorders and depression in older adults. Clinical geriatrics, 16, 25. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3839957/pdf/nihms499065.pdf
Terman, M. (2007). Evolving applications of light therapy. Sleep Medicine Review, 11, 497-507. doi:10.1016/j.smrv.2007.06.003