Journal of Psychiatric Research 87 (2017) 61e70

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/psychires

Effects of smartphone use with and without blue light at night

in healthy adults: A randomized, double-blind, cross-over,
placebo-controlled comparison
Jung-Yoon Heo a, Kiwon Kim a, Maurizio Fava b, David Mischoulon b,
George I. Papakostas b, Min-Ji Kim c, Dong Jun Kim a, d, Kyung-Ah Judy Chang a,
Yunhye Oh a, Bum-Hee Yu a, Hong Jin Jeon a, b, d, *
a
Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
b
Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, USA
c
Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
d
Department of Health Sciences & Technology, Department of Medical Device Management and Research, and Department of Clinical Research Design and
Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: Smartphones deliver light to users through Light Emitting Diode (LED) displays. Blue light is the most
Received 30 July 2016 potent wavelength for sleep and mood. This study investigated the immediate effects of smartphone blue
Received in revised form light LED on humans at night. We investigated changes in serum melatonin levels, cortisol levels, body
26 October 2016
temperature, and psychiatric measures with a randomized, double-blind, cross-over, placebo-controlled
Accepted 9 December 2016
design of two 3-day admissions. Each subject played smartphone games with either conventional LED or
suppressed blue light from 7:30 to 10:00PM (150 min). Then, they were readmitted and conducted the
Keywords:
same procedure with the other type of smartphone. Serum melatonin levels were measured in 60-min
Blue light
Smartphone
intervals before, during and after use of the smartphones. Serum cortisol levels and body temperature
Melatonin were monitored every 120 min. The Profile of Mood States (POMS), Epworth Sleepiness Scale (ESS),
Cortisol Fatigue Severity Scale (FSS), and auditory and visual Continuous Performance Tests (CPTs) were
Body temperature administered. Among the 22 participants who were each admitted twice, use of blue light smartphones
was associated with significantly decreased sleepiness (Cohen's d ¼ 0.49, Z ¼ 43.50, p ¼ 0.04) and
confusion-bewilderment (Cohen's d ¼ 0.53, Z ¼ 39.00, p ¼ 0.02), and increased commission error
(Cohen's d ¼ 0.59, t ¼ 2.64, p ¼ 0.02). Also, users of blue light smartphones experienced a longer time
to reach dim light melatonin onset 50% (2.94 vs. 2.70 h) and had increases in body temperature, serum
melatonin levels, and cortisol levels, although these changes were not statistically significant. Use of blue
light LED smartphones at night may negatively influence sleep and commission errors, while it may not
be enough to lead to significant changes in serum melatonin and cortisol levels.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Smartphones have become ubiquitous in daily life. The average
smartphone use time is increasing and nearly doubled from 98 min
in 2011 to 195 min in 2013 (Sale and Scott, 2014). A nationwide
community survey conducted in the United States reported that
39% of Americans used cell phones in their bedroom in the hour
* Corresponding author. #81 Irwon-dong, Gangnam-gu, Seoul 06351, South
Korea.
E-mail address: jeonhj@skku.edu (H.J. Jeon).
prior to sleep; the rate was twice as high in adolescents and young
adults (Gradisar et al., 2013). Smartphones are often equipped with
a light-emitting diodes (LED) display, which delivers bright light to
the human eye. Smartphone LED light is an important source of
artificial light at night (ALAN). ALAN influences the circadian
regulation of the sleep-wake cycle (Gonzalez and Aston-Jones,
2006), suppresses melatonin secretion (Czeisler et al., 1995; Lewy
et al., 1980), alters mood and cognitive functions (LeGates et al.,
2012), and contributes to fatigue (Meesters and Lambers, 1990).
Advantages of LED display over incandescent light sources
include lower energy consumption, longer lifespan of electronic

http://dx.doi.org/10.1016/j.jpsychires.2016.12.010
0022-3956/© 2016 Elsevier Ltd. All rights reserved.
62 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70
devices. However, LED-based light sources differ from traditional
lamps in that they contain higher proportions of short-wavelength
blue light ranging from 450 to 470 nm, which is more likely to cause
problems, such as blue light hazard, when people look directly into
these bright and point-like sources at night (Federation of National
Manufacturers' Associations for Luminaires and Electrotechnical
Components for Luminaires, 2011). Blue light hazard is defined as
the potential for a photochemical induced retinal injury resulting
from electromagnetic radiation exposure of short-wavelength blue
light (Algvere et al., 2006).
Also, compared to light with longer wavelengths, light of short
wavelength has been shown to have a larger suppressing effect on
melatonin concentrations (Brainard et al., 2001; Cajochen et al.,
2005). Not all studies have found effects of melatonin suppres-
sion when blue light devices have been used at night (Heath et al.,
2014; Wood et al., 2013). However, Wood et al. mentioned that
exposure to blue light LED of self-luminous tablets significantly
reduced melatonin levels after 2 h, compared to orange LED (Wood
et al., 2013).
Blue light therapy in the morning may be effective for the
treatment of depression with a seasonal pattern (Gagne et al., 2011)
and depression among the elderly (Lieverse et al., 2011), but blue
light exposure at night and in relatively low room light conditions
increases secretion of human melatonin and can thus lead to
insomnia (Chellappa et al., 2013) and increased vigilance among
night workers (Sasseville et al., 2006). Smartphone users exposed
to bright blue light from the phone's LED display at night may be
affected as well. However, no previous controlled studies have
addressed this issue.
The purpose of the present study was to investigate the impact
of smartphone LED displays with blue light at night, compared to
LED displays with suppressed blue light. The two types of LED
displays were indistinguishable from each other with the naked eye
because other wavelengths were used to mimic blue light in the
suppressed LED. The main hypothesis was that exposure to a
smartphone LED display with blue light at night suppresses mela-
tonin increase, decreases sleepiness, and impairs cognitive perfor-
mance, compared to the effects of the smartphone LED display
without blue light.
2. Methods
2.1. Subjects
Subjects were recruited through advertisement. All study sub-
jects were recruited at the Samsung Medical Center from
September 2013 to February 2014 through web postings and online
advertisements. Eligibility for the study was assessed with an in-
person interview using the Structured Clinical Interview for DSM-
IV Disorders (SCID) (First et al., 1995), self-reported medical his-
tory, a series of self-report questionnaires, and physical examina-
tions. All subjects participated voluntarily. In order to control for
the influence of the fluctuation of female reproductive hormones,
this study consisted of only middle-aged adult males (Baker and
Driver, 2007; LeRoux et al., 2014; Maki et al., 2015; Toffol et al.,
2014). Healthy males, 20e40 years of age, who understood the
study procedure and agreed to participate after being fully
informed about the study were included. The exclusion criteria
consisted of the following: (1) psychiatric disorders based on the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
criteria (American Psychiatric Association, 1994); (2) cognitive or
neurological disorders; (2) alcohol or substance abuse; (3) unstable
or serious medical illness; (4) current use of psychoactive media-
tions including antidepressants, anxiolytics, neuroleptics, anticon-
vulsants, hypnotics, or stimulant medications; (5) primary sleep
disorder; (6) habitual sleep onset earlier than 21:00 or later than
24:00; (7) shift worker; (8) travel across more than two time zones
within 90 days of the study; and (9) ophthalmologic disease during
the study period.
The experimental and informed consent procedures were
approved by the Institutional Review Board of Samsung Medical
Center, and the study was conducted in accordance with the
principles outlined in the Declaration of Helsinki.
2.2. Protocol
The study had a randomized, double-blind, cross-over, placebo-
controlled design. The experimental protocol included two 2-night/
3-day admissions in the Samsung Medical Center Clinical Research
Unit. This study involved two 3-day admissions to the Clinical
Research Center in order to strictly control the environment and
had a randomized, double-blind, cross-over, placebo-controlled
design to control for confounding variables, such as individual
variations, environment, diet, stress, activities, and menstrual cycle.
Participants were asked to keep a regular sleep/wake schedule for 1
week prior to the experimental period as well as during the 3-day
experimental period. Each 3-day admission consisted of a 24-h
baseline phase assessment, an experimental night, and post-
treatment phase assessment (Fig. 1) (ClinicalTrials.gov Identifier:
NCT02690311). On the first day of the experiment, subjects arrived
at the clinical research center at 9:00 a.m. Study subjects were
required to maintain a stable sleep schedule, consisting of 8 h of
sleep as well as fixed bedtimes and wake up times (based on each
individual's habitual schedule). The Clinical Research Center strictly
controlled the subjects' environment; all subjects had the same
type of bed and diet, and remained inside the unit throughout this
study.
Two types of smartphones were used. One type had a conven-
tional LED display with the full range of blue light. The other type of
smartphone had an LED display that was newly developed by
Samsung Display using blue intensity modulation technology to
suppress the blue light portion of the spectrum (wavelengths
450e470 nm). This blue intensity modulation technology is related
to asymmetric visual fatigue of cone cells under a different light
spectrum. The two types of smartphones were indistinguishable
from each other with the naked eye because other wavelengths
mimicked blue light in the suppressed LED (Fig. 2).
On the second day of the first admission, the subjects played
smartphone games (Vector Pinball, Bubble Shooter, and Memory
game) using one type of smartphone from 7:30 p.m. to 10:00 p.m.
(150 min) in a dimly-lit room, with all other experimental condi-
tions controlled. Room illumination was kept low (<3 lux) from
7:00 p.m. to 8:00 a.m. on day 2 and from 7:00 p.m. to 11: 00 p.m. on
day 3. The screen was maintained at a distance 25 cm away from
the eyes. Subjects’ phone use, including game scores, was moni-
tored. Each subject was readmitted one week later, and the process
was repeated using the other type of smartphone. The order of the
conditions was determined by a computer generated random
sequence.
2.3. Blood and temperature measures
Blood collection was performed through an intravenous cannula
inserted at admission with a heparin lock to minimize stimulation
during blood sampling. Nocturnal measurements were made every
60 min for serum melatonin and every 120 min for serum cortisol
and core body temperature (see Fig. 3). Subjects were evaluated
from 7:00 p.m. on day 1e8:00 a.m. on day 2, from 7:00 p.m. on day
2e8:00 a.m. on day 3, and from 7:00 p.m. to 11:00 p.m. on day 3.
From an hour before sampling time (6:00 p.m.) to 7:30 p.m.,
 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70
Fig. 1. Schematic diagram of the two 3-days admissions of experimental protocol.
Each admission consisted of (night 1) a baseline assessment of circadian temperature and melatonin rhythms, (night 2) use smartphone LED with or without blue light
(450e470 nm portion of the wavelength), and (night 3) after use measurements.
participants put on orange tinted goggles in order to filter out short
wavelengths (below 539 nm).
Serum melatonin levels were measured by an enzyme-linked
immunosorbent assay (ELISA; Melatonin ELISA Human Kit; IBL,
Hamburg, Germany), and serum cortisol was measured with a
chemiluminescence immunoassay using an ADVIA Centaur auto-
mated analyzer (Siemens Healthcare Diagnostics, Tarrytown, NY,
USA) (Baek et al., 2014). All melatonin levels (in pg/mL) were con-
verted to a percentage of the maximum level of melatonin obtained
during the night (average of the three highest values). The time that
melatonin levels rose to 50% of maximum (DLMO 50%) was selected
as the phase marker for this analysis. DLMO 50% was recorded each
night of blood sampling. The suppressing effect of light on con-
centration during the 150 min of light exposure was estimated for
each subject as the difference between the area under the curve
(AUC) before and after display exposure (AUC pgh/ml). The AUC of
63
serum melatonin and cortisol was calculated from 8 p.m. on day
2e8 a.m. on day 3.
2.4. Sleep and psychiatric measures
The Profile of Mood States (POMS), Epworth Sleepiness Scale
(ESS), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index
(PSQI), and auditory and visual Continuous Performance Tests
(CPTs) were administered.
2.5. Profile of mood states (POMS)
Mood was measured using the POMS (McNair et al., 1989), a
well-validated self-report measure of mood states. The original
English version consists of 65 items that assess the participant's
current mood on a six-point Likert scale (0 ¼ not at all,
64 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70
Fig. 2. Relative differences in light luminance at three wavelengths between the two types of smartphone LED displays.
5 ¼ extremely). The Korean version of the POMS was used in this
study (Kim et al., 2003). The internal consistency coefficient (a) of
K-POMS was 0.93 and ranged from 0.67 to 0.90 for subscales. An-
swers provide standardized scores for six identified subscales:
anger-hostility, confusion-bewilderment, depression-dejection,
fatigue-inertia, tension-anxiety, and vigor-activity. Higher scores
indicate more negative mood states, except for vigor-activity, for
which lower scores denote a more negative mood state. The POMS
has high internal consistency as well as predictive and constructive
validity.
2.6. Epworth Sleepiness Scale (ESS)
The ESS (Johns, 1994) is comprised of eight questions that query
the subject's likelihood of dozing off or falling asleep in situations
that are common in daily life. Each ESS item score measures a
particular “situational sleep propensity”, and the sum of those item
scores (i.e., the total ESS score) measures the subject's average sleep
propensity across those different situations in daily life (Johns,
1994). The Korean version of the ESS (Cho et al., 2011) is a reli-
able and valid tool for screening patients with daytime sleepiness
in Korea.
2.7. Fatigue Severity Scale (FSS)
The FSS (LaChapelle and Finlayson, 1998) is composed of 9
statements (items) that describe fatigue symptoms. Considering
the past week, respondents rate how much they agree with the
statements on a 7-point scale (1 ¼ strongly disagree, 7 ¼ strongly
agree). Higher average scores indicate a greater severity of fatigue
symptoms. This scale has been shown to have good internal con-
sistency among healthy individuals. The FSS demonstrated an
excellent internal consistency (Cronbach's a ¼ 0.93) and item-total
correlations ranged from 0.56 to 0.90 in Korean (Lee et al., 2013).
2.8. Pittsburgh Sleep Quality Index (PSQI)
The PSQI (Buysse et al., 1989) evaluates subjective sleep quality
during the previous month and can distinguish good sleepers from
poor sleepers. The PSQI-K, the Korean version of the PSQI, is a
reliable and valid questionnaire for evaluating sleep quality. The
PSQI-K total score has been shown to have a Cronbach's a
coefficient of 0.84, which shows high internal consistency and
reliability (Sohn et al., 2012). It is a self-administered questionnaire
examining seven different components of sleep quality through 24
questions, each with four possible answers. The answers are scored
from 0 to 3 (0 ¼ best). The PSQI total score is the sum of the score of
all domains and can range from 0 to 21. A total score of at least 5
characterizes poor sleepers.
2.9. Continuous performance test (CPT)
Integrated visual-auditory CPTs were performed on days 1 and 3
by a psychologist who was an expert on cognitive tests (Buchsbaum
et al., 1988). These tests can measure correct responses, reaction
time, omission errors, and commission errors, so they were applied
to measure the attention of the subjects (Jeon et al., 2014b). Reac-
tion time is defined as the amount of time between the presenta-
tion of the stimulus and the subject's response. Omission errors
indicate the number of times the subject does not provide a
response after the target is presented. Commission errors indicate
the number of times the subject responds without the presentation
of a target. Commission errors provide information about cognitive
functions, such as impulsivity control (Conners et al., 2003), self-
regulation, and inhibitory control (Riccio et al., 2001).
2.10. Data analyses
Primary outcome measures were DLMO 50%, cortisol peak time,
and body temperature. Secondary outcome measures were POMS,
ESS, FSS, visual and auditory controlled CPT, and quantity of
melatonin and cortisol secretions. The differences in demographic
data were analyzed using independent t-tests and chi-square tests.
We applied paired t-test or the Wilcoxon signed rank test to assess
changes in the measures between before and after smartphone use.
The chances of obtaining false-positive results (type I errors) when
multiple pair wise tests are performed on a single set of data were
reduced by the Bonferroni correction (p < 0.05) by dividing the P-
value by the number of comparisons being made. AUC above
baseline were applied to evaluate quantity of melatonin and
cortisol secretions. Mixed model analysis for the time*group
interaction effect was applied to compare the trend in body tem-
peratures changes from 7:00PM to 11:00PM between the two
groups.
 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70 65

Fig. 3. Changes of serum melatonin and cortisol levels, and body temperature after use of smartphone LED with and without blue light.
66 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70

Statistical analyses were performed using SAS version 9.3 (SAS When the measurements taken before and after LED exposure
Institute, Cary, NC, USA). were compared for each group, subjects who used smartphone
with blue light LED showed significant decreases in tension-
3. Results anxiety, vigor-activity, and fatigue. On the other hand, subjects
who used smartphones without blue light LED showed decreases in
3.1. Psychiatric and cognitive changes commission error after smartphone use.

The 22 men enrolled in the study completed two 3-day ad-
missions at the Clinical Research Center. Their profiles are sum-
marized in Table 1. Mean age was 30.95 ± 4.15 years.
In the between group comparison, subjects who used smart-
phones with blue light showed significantly decreased sleepiness
(Cohen's d ¼ 0.49, Z ¼ 43.50, p ¼ 0.04) and confusion-
bewilderment (Cohen's d ¼ 0.53, Z ¼ 39.00, p ¼ 0.02), and
increased commission error (Cohen's d ¼ 0.59, t ¼ 2.64,
p ¼ 0.02) after smartphone use, compared with those who used
smartphones without blue light LED (Table 2). No significant dif-
ferences were found between the two groups in tension-anxiety,
depression, anger-hostility, vigor-activity, fatigue, correct
response, omission error, and reaction times of auditory CPT and
visual CPT.
3.2. Blood measures and body temperatures
Fig. 1 depicts changes in serum melatonin levels, cortisol levels,
and body temperature before and after use of smartphones with
and without blue light LED. Use of smartphone LED display with
blue light was associated with increased body temperature as well
as lower levels and later onset of melatonin secretion (Table 3). The
150-min exposure to smartphone LED with blue light induced a
14.4-min (0.24 h; 2.94 vs. 2.70 h) phase delay of DLMO50%
compared with non-blue light LED exposure. Body temperature
increased 0.1  C and decreased 0.08  C after using smartphones
with blue light and without blue light, respectively. There were no
significant differences in serum melatonin and cortisol levels be-
tween the two groups.

Table 1 4. Discussion
Profiles of the study subjects.
This is the first controlled study to investigate the influence of
Parameter Healthy men
(n ¼ 22) the exposure of blue light from smartphone LED displays at night
on humans. The study used newly developed smartphones that
Mean(SD)
Age (years) 30.95 ± 4.15
suppressed blue light from the LED display, with a screen appear-
SBP (mmHg) 136.68 ± 9.08 ance that was otherwise identical to the conventional blue light
DBP (mmHg) 73.91 ± 16.08 LED smartphone. Exposure to the blue light LED display at night
HR (beats/min) 72.68 ± 9.71 decreased user sleepiness and confusion-bewilderment, and
Body temperature ( C) 36.36 ± 0.26
increased commission errors. Also, blue light LED exposure pro-
Alcohol (g/week) 37.39 ± 31.8
Smoking (pack-year) 1.34 ± 3.02 longed DLMO 50% and increased body temperature; however, these
Caffeine (cup/day) 1.08 ± 1.33 results were not statistically significant.
PSQI 3.91 ± 2.00 According to previous studies, ALAN exposure was significantly
LED, Light Emitting Diode; SBP, Systolic blood pressure; DBP, Diastolic associated with the suppression of melatonin secretion (Cho et al.,
blood pressure; HR, Heart rate; PSQI, Pittsburgh Sleep Quality Index. 2015b; Higuchi et al., 2014). ALAN has been found to induce

Table 2
Comparisons of psychological and cognitive measurements before and after use of smartphones equipped with LED with or without blue light.

Variables Healthy men (n ¼ 22) Comparison of

group
LED with blue light (n ¼ 22) LED without blue light (n ¼ 22)

Before use After use Statistics Before use After use Statistics Z or t P

POMS
Tension-anxiety 33.05 ± 14.80 27.86 ± 15.82 0.02a 31.62 ± 15.97 28.05 ± 17.77 0.80 1.50 1.00
Depression 2.71 ± 4.20 1.14 ± 2.29 0.32 2.43 ± 4.74 1.10 ± 2.12 0.08 8.50 1.00
Anger-hostility 2.29 ± 4.12 2.14 ± 6.81 1.00 2.43 ± 5.04 1.24 ± 3.36 0.63 0.50 1.00
Fatigue 6.19 ± 5.84 3.62 ± 3.09 0.12 4.33 ± 3.80 3.19 ± 3.56 0.05 23.00 0.33
Vigor-activity 33.00 ± 15.17 27.52 ± 16.13 0.01b 31.62 ± 15.97 28.05 ± 17.77 0.34 39.00 0.15
Confusion-bewilderment 2.05 ± 2.40 0.95 ± 1.28 0.08 1.10 ± 1.37 1.19 ± 1.57 1.00 31.00 0.04a
ESS (Sleepiness) 6.86 ± 3.86 4.76 ± 2.49 0.02a 5.67 ± 3.23 5.67 ± 4.48 1.00 43.50 0.04a
FSS (Fatigue) 2.19 ± 0.86 1.76 ± 0.65 0.001a 1.92 ± 0.76 1.74 ± 0.73 0.08 1.59 0.13
CPT
Auditory
Correct Response 62.18 ± 1.47 61.73 ± 2.16 0.87 61.00 ± 2.96 61.95 ± 1.54 0.15 1.88 0.08
Omission Error 0.82 ± 1.47 1.27 ± 2.16 0.87 2.00 ± 2.96 1.05 ± 1.54 0.15 1.88 0.08
Commission Error 1.25 ± 1.20 1.45 ± 1.50 0.42 1.95 ± 2.16 0.85 ± 0.99 0.03b 2.64 0.02b
Reaction time 0.68 ± 0.08 0.68 ± 0.08 1.00 0.70 ± 0.11 0.70 ± 0.08 1.00 0.16 0.83
Visual
Correct Response 62.2 ± 1.2 61.5 ± 2.3 0.54 61.3 ± 3.0 61.5 ± 2.4 1.00 1.21 0.43
Omission Error 0.8 ± 1.2 1.5 ± 2.3 0.54 1.75 ± 3.0 1.5 ± 2.4 1.00 1.21 0.24
Commission Error 0.3 ± 0.5 0.5 ± 1.3 1.00 0.6 ± 1.3 0.4 ± 0.6 1.00 10.00 0.34
Reaction time 0.4 ± 0.08 0.4 ± 0.07 1.00 0.42 ± 0.08 0.41 ± 0.09 1.00 1.03 0.32

Data are shown as mean ± SD; LED, Light Emitting Diode; POMS, Profile of mood states; ESS, Epworth Sleepiness Scale; FSS, Fatigue Severity Scale; CPT,Continuous per-
formance test, P ¼ Bonferroni's corrected P value.
a
Bonferroni's corrected p < 0.05, Wilcoxon signed Rank test.
b
Bonferroni's corrected p < 0.05, paired t-test.
 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70
Table 3
Comparisons of melatonin, cortisol, and body temperature during second day of admission for smartphones equipped with LED with and without blue light.
Variable Use of Smartphone
(PM 7:30e10:00)
LED with blue light (n ¼ 22)
a
Melatonin
DLMO 50% (hours) 2.94 ± 1.66
AUC, PM 8:00e11:00 6.26 ± 1.35
a
Cortisol
Cortisol peak time (hours) 10.67 ± 3.06
AUC, PM 7:00e11:00 0.86 ± 0.64
b
Body temperature
PM 7:00 36.51 ± 0.33
PM 9:00 36.46 ± 0.31
PM 11:00 36.61 ± 0.31
PM 11:00ePM 7:00 0.10 ± 0.32
AUC, area under the curve; CT, circadian time; DLMO, dim light melatonin onset.
a
Paired t-test.
b
Mixed model analysis, time* group interaction effect.
insomnia associated with increased frequent awakenings and rapid
eye movement sleep (Cho et al., 2015a). ALAN can cause shallow
sleep and frequent arousals and can have a persistent effect on
altered brain activity (Cho et al., 2013). Melatonin suppression and
delayed melatonin onset after ALAN depends on brightness of
ALAN and age, with younger individuals being affected more
(Higuchi et al., 2014). However, previous studies have mainly
focused on the brightness of light; typically, the light source was a
lightbox rather than blue light or a smartphone LED. To our
knowledge, no previous studies have focused on smartphone LED
displays.
Decreased sleepiness at night has been found to be related to
later bedtimes and more sleep difficulties in adults (Exelmans and
Van den Bulck, 2016) and adolescents (Lemola et al., 2015). Greater
frequency of insomnia symptoms significantly predicted greater
global sleep-related daytime functional impairment and depressive
symptoms (Drake et al., 2015). In a previous nationwide study
conducted with train drivers, poor sleep quality was associated
with more human errors (Jeon et al., 2014a).
Exposure to smartphone blue light LED at night diminished
cognitive functions the next day. Daytime exposure to blue light
increases alertness and improves mood and cognitive functions in a
similar manner to the effects of caffeine (Beaven and Ekstrom,
2013; Ekstrom and Beaven, 2014). Conversely, LED display expo-
sure at night has been shown to suppress melatonin secretion,
increase subjective and objective nighttime alertness, induce
somnolence, and impair cognitive functions during daytime among
young adults (Cajochen et al., 1985). A protective effect of blue-
blocker glasses has been described, with improvements in sleep,
vigilance, and performance when exposed to ALAN (Ayaki et al.,
2016; Sasseville and Hebert, 2010). Orange-tinted blue light-
blocking glasses filter out the short wavelengths in the blue range
portion of the spectrum. Blue light-blocking glasses prevent light-
induced suppression of melatonin production and decrease alert-
ness in young adults (Sasseville et al., 2006). This alertness effect of
blue light may explain the present study's finding that confusion-
bewilderment scores of the POMS decreased after using smart-
phones with blue light but not after using smartphones without
blue light.
This study indicated that smartphone blue light LED exposure
produced a 14 min delay in DLMO50% and increased body tem-
perature by 0.1  C, although these findings were not statistically
significant. Regardless, these findings have clinical significance in
that they highlight the need to control the blue light of smartphone
LED displays to prevent sleep problems and decrease body tem-
perature. Moreover, a longer DLMO50% corresponded with delayed
67
Comparison of group
LED without blue light (n ¼ 22) Z or t p
2.70 ± 1.23 1.60 0.12
6.45 ± 1.07 2.50 0.93
9.62 ± 4.41 10.00 0.30
0.88 ± 0.57 0.09 0.93
36.59 ± 0.28
36.46 ± 0.35
36.51 ± 0.31 1.64 0.10
0.08 ± 0.30
melatonin increase. Light strongly influences the circadian timing
system in humans via non-image-forming photoreceptors in the
retinal ganglion cells. Retinal ganglion cells containing melanopsin
project to a range of targets, including the suprachiasmatic nucleus
(SCN) of the hypothalamus (Baver et al., 2008) and other regions of
the brain that are involved in non-image-forming response to light.
The pathway by which light activates the ascending arousal system
has not been elucidated, but may be mediated by the SCN (Gooley
et al., 2003; Saper et al., 2005). Short wavelength regions, including
blue light (446e477 nm) are the most potent wave-lengths that
provide circadian input for regulating melatonin secretion, circa-
dian phase shifting, acute physiological responses, and subjective
alertness.
Increased body temperature in subjects who used the blue light
LED smartphones suggests that blue light may influence the human
temperature circadian rhythm. Environmental light and SCN
interact in the regulation of body temperature, so that light sup-
presses body temperature (Scheer et al., 2005). Light-induced
melatonin suppression may be directly reflected in phase changes
of sleep propensity and core body temperature rhythms (Kubota
et al., 2002). Although body temperature was increased after blue
light exposure in the present study, the changes may be too small to
implicate any association with melatonin. Further research is
needed to investigate associations between body temperature and
blue light at night.
A prior study reported that bright light exposure in the morning
is helpful in producing positive social interactions and improving
mood among mildly seasonally affected individuals, because daily
exposure to the relevant wavelengths of light are generally low in
the winter and summer (aan het Rot et al., 2008). Blue light has
been also used as a type of therapy to treat several disorders,
including seasonal affective disorders (Gagne et al., 2011), elderly
depression (Lieverse et al., 2011), and delayed sleep phase disorder
(Gradisar et al., 2011). Thus, the development of smartphone sys-
tems that suppress blue light at night and deliver bright light in the
morning may be beneficial for sleep and mood among smartphone
users.
There are several limitations of this study that should be
considered when interpreting the findings. First, the number of
subjects was quite small. The differences between blue light and
non-blue light were not statistically significant for DLMO50%
(p ¼ 0.12 by paired t-test) and body temperature (p ¼ 0.10 by mixed
model analysis), perhaps because a relatively small sample size may
make it more difficult to distinguish between differences. Never-
theless, our study was rigorously designed, with a randomized,
double-blinded, cross-over, placebo-controlled design applied to a
68 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70
homogenous group, and utilized smartphones developed with a
new LED display with suppressed blue light. Second, females were
not included, so we were not able to evaluate gender differences.
Third, smartphone LED displays that suppress other colors, such as
red or yellow, could be informative for evaluating the influence of
blue light. Further investigations should continue to evaluate the
long-term effect of smartphone LED displays with and without blue
light and other colors, using an outpatient-based design that in-
corporates not only healthy subjects but also those with insomnia
or depression. Fourth, our study did not measure sleep itself
through the use of techniques such as polysomnography. Finding
out whether using a LED display affects sleep architecture, such as
sleep latency, could be an area for future research. Finally, some
previous studies reported that 1 h of self-luminous LED exposure
did not induce a significantly different melatonin suppression;
however this difference reached significance after 2 h of exposur-
e(Heath et al., 2014; Wood et al., 2013). In future studies, compar-
isons between groups with different durations of LED exposure
need to be considered to provide more information about the
impact of self-luminous displays on melatonin suppression.
In conclusion, this study suggests that nighttime exposure to the
blue light LED display of smartphones may negatively affect sleep
and commission errors. This was reflected by the suppression of
melatonin production, as indicated by the prolonged time to
melatonin onset, and the increase in body temperature, although
these changes were not great enough to be statistically significant.
These findings indicate that sleep and cognitive functions may be
more sensitive markers of exposure of blue light from smartphone
LED displays than the physiological changes of melatonin, cortisol,
and body temperature.
Role of funding source
The sponsors had no role in the analysis of the data, the writing
of the report, or the decision to submit the paper for publication.
Contributors
Prof. Hong Jin Jeon was a principal investigator of this study,
designed the study, and educated and supervised the interviewers,
and checked the whole data. Dr. Jung-Yoon Heo and Dr. Kiwon Kim,
Dong Jun Kim, Kyung-Ah Judy Chang, Yunhye Oh, Bum-Hee Yu and
Min-Ji Kim wrote the manuscript and analyzed the data. Prof.
Maurizio Fava, David Mischoulon, and George I. Papakostas checked
the results and supervised the analysis and manuscript.
Disclosure of any conflicts of interest
Dr. Fava has received research support from Abbott Labora-
tories, Alkermes, Aspect Medical Systems, Astra-Zeneca, Bio-
Research, BrainCells, Inc., Bristol-Myers Squibb Company,
Cephalon, Clinical Trial Solutions, LLC, Eli Lilly & Company, EnVivo
Pharmaceuticals, Inc., Forest Pharmaceuticals Inc., Ganeden, Glax-
oSmithKline, J & J Pharmaceuticals, Lichtwer Pharma GmbH, Lorex
Pharmaceuticals, NARSAD, NCCAM, NIDA, NIMH, Novartis, Organon
Inc., PamLab, LLC, Pfizer Inc, Pharmavite, Roche, Sanofi-Aventis,
Shire, Solvay Pharmaceuticals, Inc., Synthelabo, and Wyeth-Ayerst
Laboratories. He has served as an advisor and consultant to
Abbott Laboratories, Affectis Pharmaceuticals AG, Amarin, Aspect
Medical Systems, Astra-Zeneca, Auspex Pharmaceuticals, Bayer AG,
Best Practice Project Management, Inc, BioMarin Pharmaceuticals,
Inc., Biovail Pharmaceuticals, Inc., BrainCells, Inc, Bristol-Myers
Squibb Company, Cephalon, Clinical Trials Solutions, LLC, CNS
Response, Compellis, Cypress Pharmaceuticals, Dov Pharmaceuti-
cals, Eisai, Inc., Eli Lilly & Company, EPIX Pharmaceuticals,
Euthymics Bioscience, Inc., Fabre-Kramer, Pharmaceuticals, Inc.,
Forest Pharmaceuticals Inc., GlaxoSmithKline, Grunenthal GmBH,
Janssen Pharmaceutica, Jazz Pharmaceuticals, J & J Pharmaceuticals,
Knoll Pharmaceutical Company, Labopharm, Lorex Pharmaceuti-
cals, Lundbeck, MedAvante Inc., Merck, Methylation Sciences,
Neuronetics, Novartis, Nutrition 21, Organon Inc., PamLab, LLC,
Pfizer Inc, PharmaStar, Pharmavite, Precision Human Biolaboratory,
Prexa Pharmaceuticals, Inc., PsychoGenics, Psylin Neurosciences,
Inc., Ridge Diagnostics, Inc., Roche, Sanofi-Aventis, Sepracor,
Schering-Plough, Solvay Pharmaceuticals, Inc., Somaxon, Somerset
Pharmaceuticals, Synthelabo, Takeda, Tetragenex, TransForm
Pharmaceuticals, Inc., Transcept Pharmaceuticals, Vanda Pharma-
ceuticals Inc, and Wyeth-Ayerst Laboratories. He has received
speaking and publishing honoraria from Adamed, Co., Advanced
Meeting Partners, American Psychiatric Association, American So-
ciety of Clinical Psychopharmacology, Astra-Zeneca, Belvoir,
Boehringer-Ingelheim, Bristol-Myers Squibb Company, Cephalon,
Eli Lilly & Company, Forest Pharmaceuticals Inc., GlaxoSmithKline,
Imedex, Novartis, Organon Inc., Pfizer Inc, PharmaStar, MGH Psy-
chiatry Academy/Primedia, MGH Psychiatry Academy/Reed-
Elsevier, UBC, and Wyeth-Ayerst Laboratories. He holds equity in
Compellis. He currently holds a patent for SPCD and a patent
application for a combination of azapirones and bupropion in MDD,
and has received copyright royalties for the MGH CPFQ, SFI, ATRQ,
DESS, and SAFER diagnostic instruments. Dr Mischoulon has
received research support from the Bowman Family Foundation,
FisherWallace, Ganeden, Nordic Naturals, and Methylation Sci-
ences, Inc. (MSI). He has received honoraria for consulting,
speaking, and writing from the Massachusetts General Hospital
Psychiatry Academy. He has received royalties from Lippincott
Williams & Wilkins for a published book entitled “Natural Medi-
cations for Psychiatric Disorders: Considering the Alternatives.” No
payment has exceeded $10,000. Other authors have no conflict of
interest. Dr. Papakostas has served as a consultant for Abbott
Laboratories, AstraZeneca PLC, Brainsway Ltd, Bristol-Myers Squibb
Company, Cephalon Inc., Dey Pharma, L.P., Eli Lilly Co., Glax-
oSmithKline, Evotec AG, H. Lundbeck A/S, Inflabloc Pharmaceuti-
cals, Jazz Pharmaceuticals, Novartis Pharma AG, Otsuka
Pharmaceuticals, PAMLAB LLC, Pfizer Inc., Pierre Fabre Laboratories,
Ridge Diagnostics (formerly known as Precision Human Bio-
laboratories), Shire Pharmaceuticals, Sunovion Pharmaceuticals,
Takeda Pharmaceutical Company LTD, Theracos, Inc., and Wyeth,
Inc. Dr. Papakostas has received honoraria from Abbott Labora-
tories, Astra Zeneca PLC, Bristol-Myers Squibb Company, Brainsway
Ltd, Cephalon Inc., Dey Pharma, L.P., Eli Lilly Co., Evotec AG, Glax-
oSmithKline, Inflabloc Pharmaceuticals, Jazz Pharmaceuticals, H.
Lundbeck A/S, Novartis Pharma AG, Otsuka Pharmaceuticals,
PAMLAB LLC, Pfizer, Pierre Fabre Laboratories, Ridge Diagnostics,
Shire Pharmaceuticals, Sunovion Pharmaceuticals, Takeda Phar-
maceutical Company LTD, Theracos, Inc., Titan Pharmaceuticals,
and Wyeth Inc. Dr. Papakostas has received research support from
AstraZeneca PLC, Bristol-Myers Squibb Company, Forest Pharma-
ceuticals, the National Institute of Mental Health, PAMLAB LLC,
Pfizer Inc., Ridge Diagnostics (formerly known as Precision Human
Biolaboratories), Sunovion Pharmaceuticals, and Theracos, Inc. Dr.
Papakostas has served (not currently) on the speaker's bureau for
Bristol Myers Squibb Co and Pfizer, Inc. Dr. Jeon, Heo, Kim, Oh, and
Yu have no conflicts of interest.
Acknowledgements
This research was supported by Samsung Display (S-2014-1823-
000). This research was also supported by the Original Technology
Research Program for Brain Science through the National Research
Foundation of Korea (NRF) funded by the Ministry of Education,
 J.-Y. Heo et al. / Journal of Psychiatric Research 87 (2017) 61e70
Science and Technology (No. NRF-2016M3C7A1947307; PI, Hong Jin
Jeon), and by a grant of the Korean Mental Health Technology R&D
Project, Ministry of Health & Welfare, Republic of Korea (No.
HM14C2567) (PI: Hong Jin Jeon). The authors thank the Statistics
and Data Center, Research Institute for Future Medicine, Samsung
Medical Center, Chief Dr. Seonwoo Kim for statistical support. These
funding sources were not involved in the creation of the study
protocol, data analysis, or in writing the manuscript.
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