Seasonal Affective Disorder: Common Questions and Answers

 

Seasonal affective disorder is a mood disorder that is a subtype or qualifier of major depressive disorder or bipolar disorder in the Diagnostic and Statistical Manual of Mental Disorders. It is characterized by depressive symptoms that occur at a specific time of year (typically fall or winter) with full remission at other times of year (typically spring or summer). Possible risk factors include family history, female sex, living at a more northern latitude, and young adulthood (18 to 30 years of age). With the temporal nature of the mood episodes, diagnosis requires full remission when the specified season ends and two consecutive years of episodes in the same season. First-line therapy for seasonal affective disorder includes light therapy, antidepressants, and cognitive behavior therapy, alone or in combination. Commercial devices are available for administering light therapy or dawn simulation. The light intensity and duration of treatment depend on the device and the patient's initial response, but 2,500 to 10,000 lux for 30 to 60 minutes at the same time every day is typically effective. Lifestyle interventions, such as increasing exercise and exposure to natural light, are also recommended. If seasonal affective disorder recurs, long-term treatment or preventive intervention is typically indicated, and bupropion appears to have the strongest evidence supporting long-term use. Continuing light therapy or other antidepressants is likely beneficial, although evidence is inconclusive. Evidence is also inconclusive for psychotherapy and vitamin D supplementation.

Seasonal affective disorder (SAD) is a mood disorder with depressive symptoms that occur at a specific time of year with full remission at other times of year. It typically occurs during fall or winter, although a less common form occurs during spring or summer.1,2 The pathophysiology is unclear, but theories include circadian rhythm disruption, dysregulation of the melanopsin signaling pathway and its impact on serotonin reuptake, and dysfunction of the hypothalamic-pituitary-adrenal axis.35 Studies using interviews and diagnostic criteria in the United States, Canada, and United Kingdom show a lifetime prevalence of 0.5% to 2.4% in the general population.68 Of patients with major depression, 10% to 20% have a seasonal pattern of symptoms consistent with SAD.9

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Light therapy, dawn simulation, and cognitive behavior therapy are effective treatments for SAD.25,26,29,30

A

Consistent evidence from a Cochrane review

Selective serotonin reuptake inhibitors may play a role in the treatment of SAD.27,28

B

Low-quality evidence from two RCTs in a Cochrane review (fluoxetine [Prozac]) and from one RCT (sertraline [Zoloft])

Bupropion (Wellbutrin) may prevent SAD recurrence and is the only pharmacotherapy labeled for this use.35,36

A

Consistent evidence from a Cochrane review of three RCTs

There is insufficient evidence to recommend antidepressants other than bupropion, light therapy, mindfulness-based cognitive therapy, or vitamin D supplementation for the prevention of SAD. Interventions should be individualized.33,37,42

B

Low-quality evidence from limited RCTs and one non–patient-oriented systematic review


RCT = randomized controlled trial; SAD = seasonal affective disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Light therapy, dawn simulation, and cognitive behavior therapy are effective treatments for SAD.25,26,29,30

A

Consistent evidence from a Cochrane review

Selective serotonin reuptake inhibitors may play a role in the treatment of SAD.27,28

B

Low-quality evidence from two RCTs in a Cochrane review (fluoxetine [Prozac]) and from one RCT (sertraline [Zoloft])

Bupropion (Wellbutrin) may prevent SAD recurrence and is the only pharmacotherapy labeled for this use.35,36

A

Consistent evidence from a Cochrane review of three RCTs

There is insufficient evidence to recommend antidepressants other than bupropion, light therapy, mindfulness-based cognitive therapy, or vitamin D supplementation for the prevention of SAD. Interventions should be individualized.33,37,42

B

Low-quality evidence from limited RCTs and one non–patient-oriented systematic review


RCT = randomized controlled trial; SAD = seasonal affective disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the

The Authors

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SAMUEL V. GALIMA, DO, FAAFP, is a brigade surgeon at Fort Sill, Okla. At the time this article was written, he was a family physician at Landstuhl Regional Medical Center, Germany....

STEPHEN R. VOGEL, MD, is a brigade surgeon at Fort Hood, Tex. At the time this article was written, he was a family physician at Guthrie Ambulatory Health Clinic, Fort Drum, N.Y.

ADAM W. KOWALSKI, MD, is a brigade surgeon at Fort Stewart, Ga. At the time this article was written, he was a family physician at Hawks Troop Medical Clinic, Fort Stewart.

Address correspondence to Samuel V. Galima, DO, FAAFP (email: sgalima@atsu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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