S. ATEZAZ SAEED, M.D., and TIMOTHY J. BRUCE, PH.D., college of Illinois college of medicine at Peoria, Peoria, Illinois

Am Fam Physician. 1998 Mar 15;57(6):1340-1346.

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See connected patient info handout on seasonal affective disorder, created by the writer of this article.


Seasonal affective disorder is a sample of major depressive episodes the occur and remit with transforms in seasons. It might be seen in major depressive or bipolar disorders, as defined in the Diagnostic and also Statistical hand-operated of mental Disorders (DSM-IV). The many recognized type of seasonal affective disorder, “winter depression,” is characterized by recurrent illustration of depression, hypersomnia, augmented appetite through carbohydrate craving, and also weight obtain that begin in the autumn and also continue with the winter months. Physicians have actually many alternatives for treating seasonal affective disorder. When questions about the validity the seasonal affective disorder together a syndrome and also the device of action of light therapy proceed to it is in investigated, the established effectiveness the light therapy in patients with winter depression supports the usefulness of assessment for this seasonal pattern and consideration of light therapy as an option in enhancement to existing treatment choices.


Depressive episodes are a primary public health problem and also one of the most typical psychiatric conditions in patients seeing household physicians, v a lifetime prevalence of 17.1 percent in the general population.1 few of these atmosphere disturbances follow continuous seasonal patterns. This seasonal mood patterns have actually been termed seasonal affective disorders (SADs).


The Diagnostic and Statistical hand-operated of mental Disorders (DSM-IV) explains SAD no as a different mood disorder yet as a “specifier,” referring to the seasonal sample of major depressive episodes the can happen within significant depressive and also bipolar disorders.2

Table 1 summarizes the DSM-IV criteria because that a major depressive episode. Table 2 describes the diagnostic criteria because that “seasonal sample specifier.”


TABLE 1Diagnostic Criteria because that a major Depressive Episode

A. At least five of the following symptoms have actually been existing during the exact same two-week period, practically every day, and also represent a adjust from ahead functioning. At least one that the symptoms is either (1) depression mood or (2) ns of attention or pleasure.

note: execute not encompass symptoms that are clearly due come a general medical condition, or mood-incongruent delusions or hallucinations.

(1) depression mood (or additionally can be irritable atmosphere in children and adolescents).

(2) Markedly reduced interest or satisfied in all, or almost all, activities.

(3) far-reaching weight loss when not dieting or weight obtain or diminish or boost in appetite.

(4) Insomnia or hypersomnia.

(5) Psychomotor agitation or retardation.

(6) fatigue or ns of energy.

(7) feeling of useless or excessive or unreasonable guilt.

(8) Diminished capability to think or concentrate, or indecisiveness.

(9) Recurrent thoughts of fatality (not just fear of dying), recurrent suicidal ideation there is no a details plan, or a self-destruction attempt or a details plan because that committing suicide.

B. The symptoms space not better accounted because that by a mood disorder as result of a basic medical condition, a substance-induced atmosphere disorder, or bereavement (normal reaction to the death of a loved one).

C. The symptoms space not better accounted for by a psychotic disorder prefer schizoaffective disorder.



TABLE 1Diagnostic Criteria because that a major Depressive Episode

A. At least 5 of the adhering to symptoms have actually been existing during the very same two-week period, nearly every day, and also represent a readjust from vault functioning. At the very least one of the symptom is one of two people (1) depressed mood or (2) lose of attention or pleasure.

note: do not encompass symptoms that are plainly due come a general medical condition, or mood-incongruent delusions or hallucinations.

(1) depression mood (or conversely can be irritable the atmosphere in children and also adolescents).

(2) Markedly decreased interest or pleasure in all, or nearly all, activities.

(3) far-reaching weight loss when not dieting or weight acquire or to decrease or increase in appetite.

(4) Insomnia or hypersomnia.

(5) Psychomotor agitation or retardation.

(6) fatigue or loss of energy.

(7) feeling of worthlessness or too much or unreasonable guilt.

(8) Diminished ability to think or concentrate, or indecisiveness.

(9) Recurrent thoughts of fatality (not just fear of dying), recurrent suicidal ideation without a particular plan, or a suicide attempt or a certain plan because that committing suicide.

B. The symptoms are not better accounted for by a mood disorder because of a general medical condition, a substance-induced mood disorder, or bereavement (normal reaction come the fatality of a loved one).

C. The symptoms space not better accounted because that by a psychotic disorder choose schizoaffective disorder.



TABLE 2Criteria for Seasonal pattern Specifier

A. Constant temporal relationship in between the onset of significant depressive episodes and a specific time the the year (unrelated to evident season-related psychosocial stressors)

B. Complete remissions (or a readjust from depression come mania or hypomania) additionally occur in ~ a characteristics time of the year

C. Two major depressive episodes meeting criteria A and also B in last two years and also no nonseasonal illustration in the exact same period

D. Seasonal major depressive episodes significantly outnumber the nonseasonal episodes over the individual"s lifetime



TABLE 2Criteria because that Seasonal sample Specifier

A. Constant temporal relationship between the start of major depressive episodes and also a particular time of the year (unrelated to apparent season-related psychosocial stressors)

B. Full remissions (or a adjust from depression to mania or hypomania) also occur at a characteristic time of the year

C. Two major depressive episodes conference criteria A and also B in last two years and also no nonseasonal episodes in the very same period

D. Seasonal major depressive episodes significantly outnumber the nonseasonal episodes over the individual"s lifetime



Two seasonal patterns have actually been identified. The most often recognized is the fall-onset type, additionally known together “winter depression,” in which major depressive episodes start in the late autumn to early winter months and remit during the summer months. Atypical signs and also symptoms the depression2 predominate in cases of winter depression and include the following: (1) boosted rather than reduced sleep; (2) increased rather than diminished appetite and food intake through carbohydrate craving; (3) marked increase in weight; (4) irritability; (5) interpersonal challenges (especially rejection sensitivity), and also (6) leaden paralysis (a heavy, leaden feeling in the eight or legs).

A spring-onset sample (summer depression) additionally has been described, in i m sorry the severe depressive episode begins in late feather to beforehand summer and also is defined by usual vegetative symptom of depression, together as lessened sleep, load loss and also poor appetite.3

Recent studies report that most episodes of SAD happen within unipolar significant depressive disorders, back a an extensive minority have accompanying hypomanic episodes (bipolar II disorder, follow to the DSM-IV), and also very few are connected with manic episodes.4


Surveys estimate that 4 come 6 percent of the general population experience winter depression, and another 10 to 20 percent have sub-syndromal features.5 Women v SAD outnumber men 4 to one. The average period of start is approximately 23 year of age.4 The hazard of SAD shows up to decrease through age.2 Pilot researches of childhood instances of SAD indicate a pervasiveness rate in between 1.7 and also 5.5 percent in children in between the eras of nine and 19 years.6


An expertise of the features and also treatment the SAD has grown in ~ the paper definition of a debate around the validity the SAD together a syndrome. Because that example, it has actually been said that seasonal variations in mood and also behavior detailed in the general population speak against SAD as a distinctive diagnostic entity.7 In addition, symptoms of SADs overlap through other, more established subtypes of depression—summer depressions with common depressive episodes and also winter depression v atypical depression.8,9 Winter depression responds to treatment with monoamine oxidase inhibitors (MAOIs),10 together does patent depression. Return summer depression has been studied less extensively than winter depression, it appears to respond to the exact same antidepressant pharmacotherapy that is used properly to treat nonseasonal depression.

Some investigators have said that the validity that SAD as a syndrome is supported by reports that the ratio of winter depression come summer depression boosts with boosting latitude and that episodes of winter depression in particular tend come be much longer and more severe at higher latitudes.11 In addition, return manipulation of factors such together heat and humidity has actually not been effective in treating summer depression, winter depression has actually responded to man-made bright light therapy, likewise known as phototherapy.12 Interestingly, nonseasonal atypical depression has not responded to phototherapy.13

This issue is further facility by the truth that return phototherapy has proved effective in the therapy of winter depression, its device of action has not been established. Numerous mechanisms have been advanced, including circadian phase shifting, or reversing the boosted melatonin, reduced 5-hydroxytryptamine and also decreased dopamine neurotransmission it was observed in SAD,4 yet it stays unestablished whether phototherapy achieves the well-documented impacts through any kind of of this or various other mechanisms. Until further research clarifies this issues, phototherapy supplies physicians second effective treatment option for plainly established situations of winter depression14 and also justifies initiatives made to determine this seasonal sample in patients v depressive episodes.


Although light therapy is uniquely efficient for winter depressive episodes, treatment planning because that patients v SAD must include factor to consider of all treatment choices available, consisting of somatic and also psychosocial treatments.

The company for Health treatment Policy and Research (AHCPR)14 has actually recently recommended practice guidelines for depression in main care, including treatment of seasonal depression. Follow to these guidelines, the use of irradiate therapy need to be taken into consideration only in patients through well-documented seasonal, non-psychotic, winter depressive episodes arising within recurrent significant depressive disorder, bipolar II disorder or milder seasonal depressive episodes. It is likewise advised that doctors unfamiliar through light treatment consult a expert who is experienced and trained in that is use. Light treatment is a first-line treatment consideration under the circumstances detailed in Table 3. That is additionally a second-line alternative in patients that fail come respond to an adequate trial the medication.


TABLE 3Circumstances sustaining the First-Line usage of light Therapy

The patience is no severely suicidal.

There are clinical reasons to protect against the use of antidepressants.

Patient has actually a background of favorable solution to light therapy.

Patient has actually no background of far-reaching negative effects to irradiate therapy.

The patient requests light therapy.

An proficient practitioner deems that light therapy is indicated.


TABLE 3Circumstances sustaining the First-Line use of irradiate Therapy

The patient is no severely suicidal.

There are medical reasons to prevent the usage of antidepressants.

Patient has a background of favorable response to irradiate therapy.

Patient has actually no background of far-reaching negative results to irradiate therapy.

The patient requests light therapy.

An skilled practitioner deems that light therapy is indicated.


Light Therapy

Light therapy is initiated with a 10,000-lux light crate directed towards the patience at a downward slant. The patient"s eyes have to remain open up throughout the therapy session, return staring straight into the light source is unnecessary and is no advised. The patient should start v a solitary 10- to 15-minute session per day, progressively increasing the session"s duration to 30 come 45 minutes. Sessions have to be boosted to twice a job if symptoms worsen. Ninety minutes a job is the conventional day-to-day maximum expression of therapy, although there is no factor to border the expression of sessions if side effects are no severe.15

Commercially accessible fixtures room recommended end homemade tools to reduce electrical risks connected with poor-quality construction. Commercial fixtures likewise include features designed to protect the eyes, such as light dispersion and screens that get rid of ultraviolet (UV) rays. Fluorescent light is desired over incandescent due to the fact that the little point resource of the last is an ext conducive come retinal damage. Use of “full-spectrum” light appears to be unnecessary.

No time of job is optimal because that light therapy. Some studies have reported the superiority of morning sessions,16 while others have presented no far-reaching difference in between times that administration.17 In the absence of clean indications, convenience must be the prevailing consideration.

Although part patients show an immediate advantage from light therapy, most take two to four days to experience a continual antidepressant response. However, a absence of an answer within the first week must not be construed as a treatment failure, due to the fact that evidence suggests that much longer durations that therapy deserve to improve an answer and the the initial solution to light have the right to take numerous weeks come appear.18 The treatment plan should it is in reevaluated, however, if the patience shows any clinical worsening or if a response is not obvious in four to six weeks.

Patients that respond to light treatment should proceed treatment until adequate daily irradiate exposure is available to castle through other sources, typically from springtime sun.4 premature birth discontinuation deserve to precipitate relapse.

Recently, irradiate visors have actually been manufactured that deserve to deliver comparable illumination in a much more convenient and also portable fashion.19 However, although studies using light boxes have argued a positive relationship between the intensity of light and also the clinical response,20 results from studies of light visors have actually not presented such a relationship. Some investigators have actually concluded the light crate operate in different ways from visors.21

It is vital to note that no proof indicates the tanning beds, wherein the eyes are normally covered and also the subject"s skin is exposed come light, are valuable in the treatment of SAD. Furthermore, the light resources in tanning bed are relatively high in UV rays, which deserve to be harmful to both the eyes and the skin.

When correctly administered, irradiate therapy shows up to have couple of side effects, none of which is irreversible. Caution is compelled when utilizing light treatment in patients with a propensity toward mania, or in those v photosensitive skin or medical conditions that render your eyes fragile to phototoxicity. Disadvantage effects linked with the usage of light therapy22 are provided in Table 4. If side impacts occur, they typically respond to a “dose” palliation (e.g., diminished duration the sessions, enhanced distance indigenous the light resource or regular breaks during sessions).


TABLE 4Adverse Effects connected with light Therapy

Photophobia

Headache

Fatigue

Irritability

Hypomania

Insomnia (if light treatment is provided too so late in the day)

Possible retinal damages (although there is no proof to date)


TABLE 4Adverse Effects connected with irradiate Therapy

Photophobia

Headache

Fatigue

Irritability

Hypomania

Insomnia (if light therapy is supplied too so late in the day)

Possible retinal damages (although there is no evidence to date)


Predictors of a positive response to irradiate therapy incorporate disorders identified by a background of hypersomnia, a preponderance of patent vegetative symptoms and also an boosted intake the sweet foodstuffs in the afternoon, as well as a background of reactivity to ambient light.23,24

Table 5 gives patient source information, including associations that carry out support to persons v SAD and also sources because that light fixtures.


TABLE 5Resources for Patients with Seasonal Affective Disorders

Places where light fixtures may be purchased:

Apollo irradiate Systems

352 West 1060 South

Orem, Utah 84058

Telephone: 800-545-9667

Hughes bright Technologies

34 Yacht club Dr.

Lake Hopatcong, NJ 07849

Telephone: 973-663-1214

Northern light Technologies

8971 Henri Bourassa West

Montreal, Canada H4S 1P7

Telephone: 800-263-0066

The SunBox Company

19217 Orbit Dr.

Gaithersburg, MD 20879

Telephone: 800-548-3968

Sources the information:

National organization for Seasonal Affective disorders (NOSAD)

P.O. Box 40190

Washington, DC 20016

(Correspondence taken on by mail only)

National Depressive and also Manic Depressive association (NDMDA)

730 N. Franklin, Suite 501

Chicago, IL 60610

Telephone: 800-82-NDMDA (800-826-3632)

Society because that Light Treatment and Biological Rhythms (SLTBR)

10200 W. 44th Ave., # 304

Wheat Ridge, CO 80033-2840

Telephone: 303-424-3697

National institute of Mental health and wellness (NIMH)

Telephone: 800-421-4211

National Mental wellness Association (NMHA)

1021 Prince St.

Alexandria, VA 22314-2971

Telephone: 800-969-6642


note: top top average, the price the a light fixture may variety between $200 and also $500, depending on the functions of the unit. Part insurance companies may reimburse all or a part of the expense of a light therapy device if suitable diagnosis has actually been made and treatment has been prescribed by a qualified health and wellness professional. Some carriers offer a rental routine for a “trying out” period.


TABLE 5Resources for Patients v Seasonal Affective Disorders

Places where light fixtures may be purchased:

Apollo irradiate Systems

352 West 1060 South

Orem, Utah 84058

Telephone: 800-545-9667

Hughes bright Technologies

34 Yacht club Dr.

Lake Hopatcong, NJ 07849

Telephone: 973-663-1214

Northern light Technologies

8971 Henri Bourassa West

Montreal, Canada H4S 1P7

Telephone: 800-263-0066

The SunBox Company

19217 Orbit Dr.

Gaithersburg, MD 20879

Telephone: 800-548-3968

Sources that information:

National company for Seasonal Affective obstacle (NOSAD)

P.O. Box 40190

Washington, DC 20016

(Correspondence taken on by mail only)

National Depressive and also Manic Depressive combination (NDMDA)

730 N. Franklin, Suite 501

Chicago, IL 60610

Telephone: 800-82-NDMDA (800-826-3632)

Society because that Light Treatment and Biological Rhythms (SLTBR)

10200 W. 44th Ave., # 304

Wheat Ridge, CO 80033-2840

Telephone: 303-424-3697

National academy of Mental wellness (NIMH)

Telephone: 800-421-4211

National Mental health and wellness Association (NMHA)

1021 Prince St.

Alexandria, VA 22314-2971

Telephone: 800-969-6642


note: on average, the price of a light fixture may variety between $200 and $500, depending upon the attributes of the unit. Some insurance companies may reimburse all or a section of the price of a light therapy maker if ideal diagnosis has been made and also treatment has actually been prescribed by a qualified wellness professional. Some service providers offer a rental regime for a “trying out” period.


Pharmacotherapy

Although data are restricted for the pharmacotherapeutic treatment of SADs specifically, the plenty of studies demonstrating the efficacy the pharmacotherapy in mood disorders, no one of which especially excluded seasonal variations, have supported the use of conventional, first-line antidepressant pharmacotherapy for SADs.14

Specific research studies of SAD have actually investigated both antidepressant and nonantidepressant drugs. Couple of of these studies, however, to be placebo-controlled. In regulated trials, fluoxetine, propranolol, and also d-fenfluramine have actually been found effective.12,25–27 open trials have also shown favorable results with moclobemide,25 tranylcypromine28 and bupropion.29 Table 6 list factors arguing the usage of medications in patients v SADs.


TABLE 6Indications because that Pharmacotherapy in Patients with Seasonal Affective Disorders

Prior positive response to antidepressants or the atmosphere stabilizers

High self-destruction risk*

Marked special needs in job-related functioning or in usual social tasks or relationships v others; significant functional impairment

History of recurrent depression in the moderate-to-severe range

Severe subtypes the depression (e.g., psychotic, melancholic, chronic)

Patient preference

Failure to respond come light treatment or psychotherapy


*—Need for hospitalization must be assessed in together cases. Also, the patient"s supply of medications, especially tricyclic antidepressants, must be restricted to protect against overdose.


TABLE 6Indications for Pharmacotherapy in Patients through Seasonal Affective Disorders

Prior positive response to antidepressants or the atmosphere stabilizers

High suicide risk*

Marked special needs in work-related functioning or in usual social tasks or relationships with others; far-ranging functional impairment

History the recurrent depression in the moderate-to-severe range

Severe subtypes that depression (e.g., psychotic, melancholic, chronic)

Patient preference

Failure to respond come light therapy or psychotherapy


*—Need because that hospitalization should be assessed in together cases. Also, the patient"s it is provided of medications, especially tricyclic antidepressants, should be limited to stop overdose.


Since SADs may occur concurrently with bipolar or unipolar disorders, the type of disorder should overview medication selection. Just like light therapy, physicians need to remain sensitive to the hazard of precipitating a manic episode in patients through bipolar disorder when using antidepressants.

Other Treatments

To ours knowledge, no managed studies have actually investigated the efficacy of electroconvulsive treatment or psychotherapy because that SAD specifically. However, very strong evidence support the efficacy that electroconvulsive therapy,30 two develops of psychotherapy (interpersonal psychotherapy31 and also cognitive therapy32), and combined psychotherapy and somatic therapy33 in the therapy of depression.

Accordingly, indications for the usage of electroconvulsive treatment in patients through SAD room the same as those in patients with nonseasonal depression and include non-response to alternative treatments, high suicide risk, psychotic depression and previous positive an answer to electroconvulsive therapy.30

At this time, interpersonal therapy and cognitive therapy space not contraindicated in patients through SAD. These varieties of psychotherapy have to be taken into consideration in patients who depressive episodes space unipolar, non-psychotic, nonsevere and also not chronic, and in those who perform not answers to, that refuse or that cannot get involved in phototherapy or pharmacotherapy. Patients v SAD might have an individual and interpersonal concerns like those developing in patients v nonseasonal depression and may benefit from the adjunctive use of psychotherapy.

The concern of whether irradiate therapy can be an unified effectively through pharmacotherapy also awaits managed study. Back several advantages can it is in hypothesized (e.g., your concurrent use might ease side effects of medicine by enabling lower dosages), current guidelines discourage the simultaneous use of irradiate therapy and medication before either one has been proved insufficient.14

Referral and Consultation

Family practice medical professionals treating patients v SAD may uncover specialty referral or consultation useful under part circumstances. AHCPR guidelines include circumstances in i m sorry referral or consultation is recommended. The guidelines are argued for usage in all types of depression and also are not certain to SADs. Since an answer to light therapy is usually evident within the first two mainly of therapy (usually within the first couple of days) and since safety and also efficacy have not been completely established beyond two weeks, the AHCPR recommends consultation through a specialist to determine details risks and also benefits because that individual patients.

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