Seasonal Affective Disorder: An Overview

Pharmacotherapy for SAD

The association of low serotonin levels with SAD makes treatment with second-generation antidepressants promising, particularly selective serotonin reuptake inhibitors.¹ A study comparing the effectiveness of fluoxetine and light therapy in SAD found fluoxetine to be equally effective, well tolerated, and more cost-effective.⁸ Bupropion has also been studied and found effective in treating SAD.¹

“[Selective serotonin reuptake inhibitors] are definitely effective, but I have not found one agent to be more superior than another,” observed Dr Schwartz.

Light Therapy

Phototherapy, or light therapy (LT), has become the “treatment of first choice” for patients with SAD.² It involves exposing patients to a bright light, usually of 10,000 lux, for 30 to 45 minutes daily, typically in the morning.²

“Bright light therapy in the morning and melatonin dosing in the evening are particularly effective, suggesting that people with seasonal depression are phase delayed. Moving the phase of the circadian rhythm earlier can lead to a decrease in depression,” Dr Schwartz said. He added that ordinary household light is insufficient to alleviate symptoms.

Light boxes can be costly, and coverage is variable, Dr Rohan added. “I have written letters to insurance companies to justify the cost of the light box. I tell them that, yes, a light box is expensive, but the cost must be weighed against the health risk that can be offset by the company’s investment.”

She cautioned that patients should not be using popularly available commercial light boxes. “I regard light boxes as medical devices, and it could be dangerous to use them to self-medicate depression.”

She noted that adherence to LT can be challenging. “Sitting in front of a device for 30 minutes per day often for as long as 5 months is quite a time commitment. Also, because LT is usually recommended first thing in the morning, it can be difficult because of morning commitments such as getting ready for work or getting children onto the school bus.”

Psychotherapeutic Approaches

“My research found that cognitive behavioral therapy…is an effective treatment, comparable to LT in treating symptoms, but more effective and durable, with fewer relapses. Also, when relapses occur, the symptoms tend to be less severe,” ^9,10 Dr Rohan reported. “We think this is because people learn skills in treatment; they learn how to think and behave differently and respond to seasonal changes differently, so they have a plan to prevent future relapse.”

Additional approaches may include meditation, mindfulness practices, yoga, walking, and physical exercise.¹

Can Treatments Be Used Prophylactically?

Treating patients prophylactically before the onset of late fall and winter has been shown effective in preventing episodes of SAD. Bupropion XL was found to prevent recurrence of seasonal depressive disorders when administered early in the season.¹¹

“When the days are beginning to shorten, it is time to find your lamp, dust it off, and begin using it,” Dr Schwartz said.

Conclusion

SAD is underdiagnosed, especially in the primary care setting, perhaps because its severity is underestimated.^12,13 “SAD does not always come to mind because seasonal depression is often thought to be mild, so it is important for clinicians to bear it in mind,” Dr Rohan said.

References

1. Melrose S. Seasonal affective disorder: An overview of assessment and treatment approaches. Depress Res Treat. 2015;2015:178564. doi: 10.1155/2015/178564.
2. Meesters Y, Gordijn MC. Seasonal affective disorder, winter type: current insights and treatment options. Psychol Res Behav Manag. 2016;9:317-327. doi: 10.2147/PRBM.S114906
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
4. Kurlansik S, Ibay AD. Seasonal affective disorder. Am Fam Physician. 2012;86(11):1037-1041.
5. Magnusson A, Partonen T. Prevalence. In: Partonen Ta, Pandi-Perumal SR, editors. Seasonal Affective Disorder: Practice and Research. 2nd ed. New York: Oxford University Press; 2010:176-184.
6. Rosenthal NE. Winter Blues: Everything You Need to Know to Beat Seasonal Affective Disorder. 4th ed. New York: Guilford Press.
7. Murray G. The Seasonal Pattern Assessment Questionnaire as a measure of mood seasonality: a prospective validation study. Psychiatry Res. 2003;120(1):53-9.
8. Hansen V, Skre I, Lund E. What is this thing called “SAD”? A critique of the concept of Seasonal Affective Disorder. Epidemiol Psichiatr Soc. 2008;17(2):120-7.
9. Traffanstedt MK, Mehta S, LoBello SG.  Major depression with seasonal variation: is it a valid construct? Clin Psychol Sci. 2016; 4(5): 825–834.
10. Penders TM, Stanciu CN, Schoemann AM, et al. Bright Light Therapy as Augmentation of Pharmacotherapy for Treatment of Depression: A Systematic Review and Meta-Analysis. Prim Care Companion CNS Disord. 2016 Oct 20;18(5)
11. Golden RN, Gaynes BN, Ekstrom RD, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry. 2005;162(4):656–662.