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Healthcare 2020, 8, 10 10 of 14 insight-oriented, and so is not easily reversible. While conventional antidepressant medications are theoretically reversible, and so technically amenable to a personalized trial approach, withdrawal effects and the timeline for onset and offset suggest that other treatments, such as light therapy, may be more suitable for testing with multiple crossover designs. 4.1. Limitations There were several limitations to our study. First, we assessed depressive symptoms using a single end-of-day VAS question, and this is not analogous to understanding treatment effects using a psychiatric interview or other more detailed depressive symptom assessments. Nevertheless, single item mood scales are more feasible for daily administration and have been strongly associated with longer instruments and clinical interviews in prior studies [26,32]. Our protocol included only one treatment repetition and our analysis plan accounted for only two possible confounders (i.e., linear trend, autocorrelation), and thus may have misattributed differences in depressive symptoms to BWL. The treatment period was limited to three weeks. While prior studies have shown that BWL can reduce depressive symptoms in as few as two weeks, a longer duration of BWL may have been needed to impact depressive symptoms in some patients [33]. The impact of seasonality was not considered. Adherence to light therapy was not objectively assessed. Future personalized trials of this nature may wish to better establish baseline symptoms prior to initiating light therapy to help clarify treatment effects. A small number of patients were enrolled. Thus, assessments of the feasibility of the smartphone-delivered personalized trial and of the pooled effect of BWL on depressive symptoms should be interpreted cautiously. 4.2. Generalizability We enrolled a small number of English-speaking cancer survivors who use smartphones into our study, which limits the understanding of the generalizability of the findings to other cancer survivors. Nevertheless, smartphones are increasingly ubiquitous, and an application could easily be translated into Spanish [34]. We also excluded cancer survivors undergoing primary cancer treatments, as personalized trials are challenging to interpret when multiple possible confounders of treatment effects occur across time. 5. Conclusions The personalized trials approach used in this study brought back the focus on the individual person that existed before the convention of pooling across many persons in between-subject RCTs [35]. We determined that there were heterogeneous treatment effects for BWL, with some patients finding a benefit and others no benefit or even harm. Further, the majority of patients recommended personalized trials of light therapy to others. Personalized trials may be ideally suited to testing the effectiveness of relatively short-acting depression treatments in cancer survivors, particularly emerging treatments for which we have a limited understanding of treatment effects. Author Contributions: Conceptualization, I.M.K., K.W.D.; methodology, I.M.K., Y.K.C., K.W.D.; formal analysis Y.K.C.; investigation, I.M.K., J.J., J.L., K.W.D.; data curation, F.P., J.L.; writing I.M.K., K.W.D.; writing—review and editing, I.M.K., Y.K.C., J.J., F.P., J.L., S.Y., H.V., D.L.H., P.G., J.S.; visualization, I.M.K., S.Y.; project administration, I.M.K., J.J., F.P., K.W.D.; funding acquisition, I.M.K., K.W.D. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded in part with Federal funds from the National Cancer Institute, NIH, under Contract No. HHSN261200800001E. Drs. Kronish, Davidson, and Cheung received additional support from the National Library of Medicine (R01LM012836). The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services or NIH nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.PDF Image | Bright White Light Therapy for Depression in Cancer Survivors
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