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Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023
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Image from Wikimedia Commons | Lou Sander.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
As shown above, light therapy is a form of treatment for seasonal affective disorder (SAD).
Characterized by a reduction in energy and interest on a seasonal basis, the best metaphor for SAD is hibernation; that is, it involves increased sleep and appetite, as would be found in animals who hibernate. The classic initial studies on SAD found that 93% of people suffering from SAD had bipolar illness.[1,2] In other words, "SAD" refers to seasonality of affective illness, most commonly with both highs and lows; it is not a separate disease.
The hallmarks of SAD are different from those of classic depression, in which people typically eat less and sleep less.
Image courtesy of Medscape.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Although not all patients with SAD have bipolar illness, it is important to screen for those who do. In SAD patients who do have bipolar illness, summer mania must be treated to prevent winter depression. The two mood states go together because they are part of a cycle, with one following the other. The psychiatric diagnostic system of the American Psychiatric Association, as found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), now views SAD as a specifier for depressive and bipolar disorders "with seasonal pattern."[3]
Image from Kraepelin,[4] reprinted in Goodwin and Jamison.[5]
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Seasonal mood episodes can be severe, but usually winter is not the peak of severity. As the above graph shows, the worst outcome, suicide, is much more common in the spring and fall.
Image courtesy of Medscape / Google Earth (Background).
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Even though full SAD is part of a mood illness, such as unipolar depression or bipolar disorder, milder seasonal mood changes can occur based on latitude. Called the "winter blues," as many as one in five people can have hibernation-like depressive symptoms in the fall/winter.[6]
As the above chart shows, latitude appears to be a significant predictor of winter blues in North America;[6] in areas that have less light during the winter, the proportion of the population with winter blues can be quite large.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
The mechanism of SAD is not completely known, but it is recognized that people with mood illnesses are sensitive to light changes. Less light lengthens the sleep-wake cycle and leads to depression; more light shortens the sleep-wake cycle and leads to mania. This effect is likely mediated by the hypothalamus, specifically the suprachiasmatic nucleus, which controls the sleep-wake cycle.[7]
Image courtesy of Medscape.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
I have produced a set of behavioral interventions that can be used to minimize the harmful impact of light in SAD, whether too much or too little. The basic idea is to increase exposure to light in the winter and decrease exposure in the summer.
In fall and winter, the most important action to take is simply to lift the bedroom shades so as to obtain as much early morning light as possible.
In spring and summer, on the other hand, when there is a relative excess of light, the most important precaution is to reduce early morning light exposure, either by using room-darkening shades (not average shades) or by sleeping with an eye mask.
Image from Wikimedia Commons | Slllu.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Light therapy, which is delivered through light boxes and dawn simulators, is an effective treatment for SAD.[8,9] The light box, which typically exposes the patient to 10,000 lux of light, should be used during the morning to replace absent sunlight.[10] (Looking directly into a light box is harmful to the eyes.)
Unlike traditional light boxes, dawn simulators come on gradually. This gradual light increase exerts a waking effect mimicking that of a natural sunrise and can be considered to have a more natural effect on circadian cycles.[11,12]
The use of light boxes should be stopped by February at the latest; if used in April, they could exacerbate mixed states (in which manic and depressive symptoms occur together) and possibly increase the risk of suicide.
Image courtesy of Medscape.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Available treatments for SAD include not only light therapy but also pharmacotherapy and psychotherapy. Although these treatments may be used alone, they are often employed in combination.[13,14]
Data on the use of psychoactive medications to treat SAD are limited. At present, among such agents, the second-generation antidepressants fluoxetine and sertraline are the best-studied in this setting and appear to be therapeutically effective for seasonal depression in persons without bipolar illness.[13,15,16]
Image courtesy of Medscape / Dreamstime | Shannon Fagan (inset).
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
A 45-year-old woman recently moved from Florida to North Carolina. In mid-November, she notices that she feels less energetic, is less interested in her usual activities, and wants to sleep more. She still functions well but must expend more effort to do so. She has had no prior psychiatric disorders or treatment.
Which of the following is the most appropriate next intervention?
Begin fluoxetine
Begin psychotherapy
Refer her to a psychiatrist
Lift the bedroom shades
Move back to Florida
Image courtesy of Dreamstime | Uptall.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Answer: D. Lift the bedroom shades.
This patient has the winter blues. The first measure to take should be the simple behavioral step of lifting the bedroom shades. If this is not effective, then light therapy can be started. Antidepressant treatment is overkill for winter blues, as opposed to full SAD. Psychotherapy has not been proven effective for winter blues, and a psychiatrist is not needed for mild mood symptoms. Moving back to Florida might work but is not the only option.
Image courtesy of Medscape / Agencyby | Dreamstime.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
A 30-year-old woman wants to begin light therapy for regular fall depression, which lasts 3 months. She has a hard time getting out of bed and leaving for work on time. She functions at work but at lower efficiency than usual. She eats more and gains about 10 pounds each winter. She has no prior psychiatric history and has never taken psychiatric medications.
What would you advise this patient regarding treatment?
Begin fluoxetine immediately
Tell her to pull up the shades in her bedroom and go for a walk every day at noon without sunglasses
Begin light box or dawn simulator therapy
B and C
All of the above
Images from Wikimedia Commons | Morn.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Answer: D. B and C.
Dawn simulators are shown above.
Light box or dawn simulator therapy certainly makes sense, but the patient also should institute the behavioral changes discussed. The two together are most effective. She does not need to begin medication right away, especially if she has not been treated with medications in the past.
Image courtesy of Medscape.
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
A 35-year-old woman has a full clinical depression lasting 2 months and consisting of low mood and energy, increased sleep and appetite, and decreased interest. She has no suicidal ideation. The episode began in late August, and she seeks treatment in mid-October. She lives on the mid-Atlantic East Coast. She had a similar depression twice in the past 5 years, again in the fall. She also had depressive episodes at least twice in the past decade at other times of the year, once in late spring and once in summer. She has a family history of bipolar disorder, which occurred in an aunt. She has been treated with venlafaxine in the past with good response but had sexual dysfunction. She once got hypomanic for a week on bupropion. She has not been treated with other medications.
The following decisions are reasonable EXCEPT:
Give her another antidepressant, like sertraline
Prescribe lithium
Begin light therapy
Raise the window shades
All of the above are reasonable
Seasonal Affective Disorder (SAD): Facts and Misconceptions
S Nassir Ghaemi, MD | November 15, 2023 | Contributor Information
Answer: A
She has unipolar depression with bipolar family history, which puts her at high risk for antidepressant mania or mixed states (which can be associated with suicidality). She has had prior manic symptomatic effects with an antidepressant, so using another agent would not be the safest option. Further, she had sexual dysfunction with a prior serotonergic drug. Lithium is a reasonable choice for acute depression, even the unipolar type, and it is especially reasonable to use with bipolar genetics. The other interventions, which are standard for seasonal depression, also could help.
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Contributor Information
Author
S Nassir Ghaemi, MD
Professor of Psychiatry, Tufts University
Lecturer on Psychiatry, Harvard Medical School
Clinical Web site: www.psychiatryletter.com
Cambridge, MA
Disclosure: S Nassir Ghaemi, MD, has disclosed no relevant financial relationships.
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