Treatment Of Seasonal Affective Disorder Research Articles

Escitalopram in Seasonal Affective Disorder: Results of an Open Trial

The aim of this study was to evaluate the efficacy and tolerability of escitalopram in the treatment of seasonal affective disorder (SAD, fall-winter depression). Twenty SAD patients were included in an 8-week drug surveillance. Patients were treated with open-label escitalopram at a dosage of 10 to 20 mg per day. Efficacy assessments included the Structured Interview Guide for the Hamilton Depression Rating Scale (SAD version; SIGH-SAD), the Clinical Global Impression (CGI) and the Social Adaptation Self Evaluation Scale (SASS). Side effects were monitored with the UKU Side Effect Rating Scale. From week 2 onwards, escitalopram significantly reduced SIGH-SAD score and CGI severity score (p<0.001). From week 4 onwards, the SASS score was also significantly improved (p<0.05). The response rate (SIGH-SAD<50% of baseline value) after treatment for 8 weeks was 95%, the rate of remission (SIGH-SAD < or =7) was 85%. Side effects were mild to moderate and did not lead to cessation of therapy. These results suggest that escitalopram is an efficacious and altogether safe treatment for seasonal depression.

Long-Term and Preventative Treatment for Seasonal Affective Disorder

Recurrent major depressive disorder with regular seasonal patterns, commonly known as seasonal affective disorder (SAD), has evoked substantial research in the last two decades. It is now recognised that SAD is a common condition with prevalence rates between 0.4% and 2.9% of the general population, and that patients with SAD experience significant morbidity and impairment in psychosocial function. There is good evidence that bright light therapy and antidepressant medications are effective for the short-term treatment of SAD; however, given that SAD is characterised by recurrent major depressive episodes, long-term and maintenance treatment must be considered. Unfortunately, there are few studies of longer term (>8 weeks) and maintenance (preventative) treatments for SAD. The weight of evidence suggests that light therapy usually needs to be continued daily throughout the winter season because of rapid relapse when light is stopped too early in the treatment period. However, some studies support the use of antidepressants to continue the response from a brief (1-2 weeks) course of light therapy early in the depressive episode, as soon as the first symptoms emerge in autumn. Only small studies have examined preventative treatment (before onset of symptoms) with light therapy, all of which have methodological limitations. The best evidence for preventative treatment in SAD comes from antidepressant studies. Three large, randomised, placebo-controlled studies have shown that preventative treatment with bupropion XL reduces the recurrence rate of depressive episodes in patients with SAD. Given the limitations in the evidence base and the inconsistent recurrence rate of winter depressive episodes, clinical recommendations for long-term and preventative treatment must individualise treatment choices and weigh potential benefits against possible adverse effects.

A randomized controlled trial of cognitive-behavioral therapy, light therapy, and their combination for seasonal affective disorder.

This first controlled psychotherapy trial for seasonal affective disorder (SAD) compared SAD-tailored cognitive-behavioral therapy (CBT), light therapy (LT), and their combination to a concurrent wait-list control. Adults (N = 61) with major depression, recurrent with seasonal pattern, were randomized to one of four 6-week conditions: CBT (1.5-hr twice-weekly group therapy), LT (10,000-lux for 90-min/day with administration time individually adjusted), combined CBT + LT, or a minimal contact/delayed LT control (MCDT; LT following 6 weeks of monitoring). CBT, LT, and CBT + LT significantly and comparably improved depression severity relative to MCDT in intent-to-treat and completer samples. CBT + LT (73%) had a significantly higher remission rate than MCDT (20%). Using prospectively measured summer mood status to estimate the "functional" population, CBT + LT also had a significantly larger proportion of participants with clinically significant change over treatment compared with MCDT. The LT condition outcomes virtually replicated results from prior trials. CBT, alone or combined with LT, holds promise as an efficacious SAD treatment and warrants further study. If replicated, CBT + LT's remission rate would represent a clinically meaningful improvement over the 53% observed across LT studies.

Agomelatine in the treatment of seasonal affective disorder

The novel antidepressant agomelatine acts as a melatonergic (MT(1) and MT(2)) receptor agonist and as a serotonin-2C receptor antagonist. Previous studies showed that agomelatine is able to restore disrupted circadian rhythms, which were implicated in the pathophysiology of seasonal affective disorder (SAD). The aim of this study was to investigate the efficacy and tolerability of agomelatine in the treatment of SAD. Thirty-seven acutely depressed SAD patients were included in an open study with agomelatine (25 mg/day in the evening) over 14 weeks. Efficacy assessments included the Structured Interview Guide for the Hamilton Depression Rating Scale (SAD version; SIGH-SAD), the Clinical Global Impression of Severity (CGI-S) and Improvement (CGI-I), the Circscreen, a self-rating scale for the assessment of sleep and circadian rhythm disorders, and the Hypomania Scale. Agomelatine led to a progressive and statistically significant decrease of SIGH-SAD, CGI-S, and CGI-I scores from week 2 onward (p < 0.001). Furthermore, scores on the Circscreen improved significantly during the study (p < 0.001). Treatment with agomelatine over 14 weeks yielded a response rate of 75.7% (SIGH-SAD <50% of baseline value) and a remission rate (SIGH-SAD <8) of 70.3% in the intention to treat sample. Scores on the Hypomania Scale were consistently low during the study. Agomelatine showed good overall tolerability: throughout the study only one adverse event (mild fatigue) was related to the study drug. The results of this study suggest that seasonal depression may be effectively and safely treated with agomelatine.

A pilot study of adherence with light treatment for seasonal affective disorder

Non-adherence with antidepressant medication regimens is now recognised as a substantial problem when evaluating depression outcome. Given the behavioural demands of light treatment (LT), it might be expected that non-adherence would be even more pronounced in LT, a form of intervention for seasonal affective disorder (SAD). However, little research has focused upon the extent to which patients in light treatment protocols adhere to set regimens. Nineteen patients with SAD were allocated to either treatment with bright white light (intervention) or dim red light (control condition) in a four-week protocol. Light exposure was estimated automatically (without participants' knowledge) with elapsed time meters built into the light box. Daily diaries were also used to measure self-reported light box use. Participants were instructed to use the light box for 30 min each day during week 1, 45 during week 2 and one hour during weeks 3 and 4 (total duration of prescribed light exposure 1365 min). The results indicated that mean duration of light box operation for the entire sample was 59.3% of the prescribed 1365 min. Six of nineteen (31.6%) patients dropped out of treatment. Amongst those completing treatment, adherence to the prescribed duration of exposure averaged 83.3% (S.D. = 31.4). A trend was found for the intervention condition to generate a lower dropout rate, as well as a trend for the degree of adherence to be greater in the intervention condition. Importantly, there was no association between adherence as measured automatically and the higher rates of self-reported adherence as measured in diaries. In summary, the results of this pilot study suggest that adherence with light treatment is of a similar order of magnitude to antidepressant medication adherence. Patient self-report was found to be unrelated to objectively estimated duration of light box use, a finding with significant research and clinical implications. Future research studies should routinely measure and evaluate adherence with light therapy and evidence-based techniques for maximising treatment adherence should be incorporated into routine clinical practice.

An Open Trial of Light Therapy in Adult Attention-Deficit/Hyperactivity Disorder

In adults with attention-deficit/ hyperactivity disorder (ADHD), a delayed sleep/ activity rhythm and/or seasonal mood symptoms may contribute significantly to core pathology and disability. This study examined whether a chronobiologically based treatment, i.e., morning bright light therapy (LT), might have utility as an adjunctive treatment for adult ADHD in the fall/ winter period. Twenty-nine adults with DSM-IV ADHD were administered a standard 3-week open trial of LT during the fall or winter months. Primary outcome measures included percentage reduction on the Brown Adult ADD Scale and the Conners' Adult ADHD Scale. Secondary measures were decrease in depression scores according to the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder version; improvements on various neuropsychological tests; and shift toward an earlier circadian preference as measured by the Horne-Ostberg Morningness-Eveningness questionnaire. Regression analyses determined which variables at baseline best predicted improvement on a given outcome measure and which variables changed in parallel with one another. The study was conducted from November 2003 through February 2004. Morning bright light therapy was associated with a significant decrease in both subjective and objective measures of core ADHD pathology, improved mood symptoms, and a significant phase advance in circadian preference. Multiple regression showed that the shift toward an earlier circadian preference with LT was the strongest predictor of improvement on both subjective and objective ADHD measures. Neither baseline global seasonality scores nor baseline depression scores strongly predicted LT effects on most measures of ADHD. These findings suggest that during the fall/winter period, LT may be a useful adjunct in many adults with ADHD. Strikingly, the strongest correlate of improvement in core ADHD pathology was a phase advance in circadian preference rather than alleviation of comorbid seasonal affective disorder, suggesting important clinical benefits of LT beyond the treatment of seasonal affective disorder.

Treatment of seasonal affective disorder

Seasonal affective disorder (SAD), winter type, is characterized by the regular annual onset of major depressive episodes during fall or winter, followed by spontaneous remission and sometimes hypomanic or manic episodes during spring and summer. SAD is clinically important, since approximately 2–5% of the general population in temperate climates are affected. Since the first description of the syndrome, researchers have made attempts to elucidate the pathophysiological background of SAD. Bright light therapy has been proposed as the treatment of choice for this disorder. However, numerous studies have also investigated suitable psychopharmacological treatments for SAD. This report is aimed to provide an overview on the clinical management and current therapeutic options for SAD.

The Importance of Routine for Preventing Recurrence in Bipolar Disorder

The Importance of Routine for Preventing Recurrence in Bipolar Disorder

The Can-SAD Study: A Randomized Controlled Trial of the Effectiveness of Light Therapy and Fluoxetine in Patients With Winter Seasonal Affective Disorder

Objective: Light therapy and antidepressants have shown comparable efficacy in separate studies of seasonal affective disorder treatment, but few studies have directly compared the two treatments. This study compared the effectiveness of light therapy and an antidepressant within a single trial. Method: This double-blind, randomized, controlled trial was conducted in four Canadian centers over three winter seasons. Patients met DSM–IV criteria for major depressive disorder with a seasonal (winter) pattern and had scores ≥23 on the 24-item Hamilton Depression Rating Scale. After a baseline observation week, eligible patients were randomly assigned to 8 weeks of double-blind treatment with either 1) 10,000-lux light treatment and a placebo capsule, or 2) 100-lux light treatment (placebo light) and fluoxetine, 20 mg/day. Light treatment was applied for 30 minutes/day in the morning with a fluorescent white-light box; placebo light boxes used neutral density filters. Results: A total of 96 patients were randomly assigned to a treatment condition. Intent-to-treat analysis showed overall improvement with time, with no differences between treatments. There were also no differences between the light and fluoxetine treatment groups in clinical response rates (67% for each group) or remission rates (50% and 54%, respectively). Post hoc testing found that light-treated patients had greater improvement at 1 week but not at other time points. Fluoxetine was associated with greater treatment-emergent adverse events (agitation, sleep disturbance, palpitations), but both treatments were generally well-tolerated with no differences in overall number of adverse effects. Conclusions: Light treatment showed earlier response onset and lower rate of some adverse events relative to fluoxetine, but there were no other significant differences in outcome between light therapy and antidepressant medication. Although limited by lack of a double-placebo condition, this study supports the effectiveness and tolerability of both treatments for seasonal affective disorder and suggests that other clinical factors, including patient preference, should guide selection of first-line treatment.

The Can-SAD Study: A Randomized Controlled Trial of the Effectiveness of Light Therapy and Fluoxetine in Patients With Winter Seasonal Affective Disorder

Light therapy and antidepressants have shown comparable efficacy in separate studies of seasonal affective disorder treatment, but few studies have directly compared the two treatments. This study compared the effectiveness of light therapy and an antidepressant within a single trial. This double-blind, randomized, controlled trial was conducted in four Canadian centers over three winter seasons. Patients met DSM-IV criteria for major depressive disorder with a seasonal (winter) pattern and had scores > or = 23 on the 24-item Hamilton Depression Rating Scale. After a baseline observation week, eligible patients were randomly assigned to 8 weeks of double-blind treatment with either 1) 10,000-lux light treatment and a placebo capsule, or 2) 100-lux light treatment (placebo light) and fluoxetine, 20 mg/day. Light treatment was applied for 30 minutes/day in the morning with a fluorescent white-light box; placebo light boxes used neutral density filters. A total of 96 patients were randomly assigned to a treatment condition. Intent-to-treat analysis showed overall improvement with time, with no differences between treatments. There were also no differences between the light and fluoxetine treatment groups in clinical response rates (67% for each group) or remission rates (50% and 54%, respectively). Post hoc testing found that light-treated patients had greater improvement at 1 week but not at other time points. Fluoxetine was associated with greater treatment-emergent adverse events (agitation, sleep disturbance, palpitations), but both treatments were generally well-tolerated with no differences in overall number of adverse effects. Light treatment showed earlier response onset and lower rate of some adverse events relative to fluoxetine, but there were no other significant differences in outcome between light therapy and antidepressant medication. Although limited by lack of a double-placebo condition, this study supports the effectiveness and tolerability of both treatments for seasonal affective disorder and suggests that other clinical factors, including patient preference, should guide selection of first-line treatment.

Seasonality of mood disorders in adults with lifetime attention-deficit/hyperactivity disorder (ADHD)

Background The objective of this study was to estimate the prevalence of Seasonal Affective Disorder (SAD) in adults with lifetime Attention-Deficit/Hyperactivity Disorder (ADHD). Method Patients eligible for this study had lifetime impairing symptoms of ADHD and a current and/or past co-morbid mood disorder according to their medical record. The Seasonal Pattern Assessment Questionnaire (SPAQ) was administered by a telephone interview to assess seasonality. Results The overall rate of SAD in this clinical population of adults with ADHD was estimated at 27%. Females were more at risk to develop SAD than men. Limitations The SPAQ is a screening, not a diagnostic instrument. Conclusions SAD symptoms are frequently comorbid with ADHD in adults. These results have clinical relevance for the recognition and treatment of SAD with bright light therapy in adults with ADHD.

Review: light therapy is an effective treatment for seasonal affective disorder

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...

O sweet spot where art thou? Light treatment of Seasonal Affective Disorder and the circadian time of sleep

This study investigated Lewy's Phase Shift Hypothesis (PSH) for winter Seasonal Affective Disorder, which asserts that the phase angle difference (PAD) between circadian and sleep rhythms is critical in the mechanism of light's therapeutic action. Specifically, we sought to test whether a euthymic "sweet spot" could be identified at a PAD (between temperature minimum and wake time) of circa 3 h. After a baseline week, symptomatic SAD patients ( N = 43) received 8 weeks of morning light treatment. Analyses were based on SIGH-SAD ratings made at baseline and posttreatment. Also estimated pre- and posttreatment were T min (calculated from an algorithm based on Morningness–Eveningness self-report scores), and the phase of the sleep–wake rhythm (as assessed by daily sleep logs). It was predicted that a quadratic relationship would exist between PAD and depression ratings at baseline and posttreatment, with lowest levels around PAD = 3 h. It was further predicted that shift towards PAD = 3 h with treatment would be associated with decreases in depression with treatment. Although trends were in the expected direction, none of the three predictions were supported. Findings are discussed in terms of the study's limitations and the experimental challenge of parsing independent and interacting contributions of sleep and circadian phase.

Light Therapy for Seasonal Affective Disorder with Blue Narrow-Band Light-Emitting Diodes (LEDs)

While light has proven an effective treatment for Seasonal Affective Disorder (SAD), an optimal wavelength combination has not been determined. Short wavelength light (blue) has demonstrated potency as a stimulus for acute melatonin suppression and circadian phase shifting. This study tested the efficacy of short wavelength light therapy for SAD. Blue light emitting diode (LED) units produced 468 nm light at 607 microW/cm2 (27 nm half-peak bandwidth); dim red LED units provided 654 nm at 34 microW/cm2 (21 nm half-peak bandwidth). Patients with major depression with a seasonal pattern, a score of > or =20 on the Structured Interview Guide for the Hamilton Depression Rating Scale-SAD version (SIGH-SAD) and normal sleeping patterns (routine bedtimes between 10:00 pm and midnight) received 45 minutes of morning light treatment daily for 3 weeks. Twenty-four patients completed treatment following random assignment of condition (blue vs. red light). The SIGH-SAD was administered weekly. Mixed-effects analyses of covariance determined that the short wavelength light treatment decreased SIGH-SAD scores significantly more than the dimmer red light condition (F = 6.45, p = .019 for average over the post-treatment times). Narrow bandwidth blue light at 607 microW/cm2 outperforms dimmer red light in reversing symptoms of major depression with a seasonal pattern.

Adjunctive Bright Light in Non‐Seasonal Major Depression

Bright light treatment is an established treatment for Seasonal Affective Disorder, but in non-seasonal depression research results have been contrasting. This study was designed as a 5-week controlled, double-blind, parallel trial in out-patients with a diagnosis (DSM-IV) of non-seasonal major depression, randomized to either active treatment (white light, 10 000 lux, 1 h daily) or placebo treatment (red light, 50 lux, 30 min daily) and concomitant treatment with sertraline in both groups. One hundred and two patients were included in the study. Analyses showed that on all used scales the reduction in depression scores was larger in the bright light group than in the dim light group, and this reached statistical significance on all observer rating scales and on the SCL-90R self-assessment scale. The HAM-D6 was the most sensitive scale to measure improvement at endpoint. The study results support the use of bright light as an adjunct treatment to antidepressants in non-seasonal depression.

Treatment of seasonal affective disorder: Unipolar versus bipolar differences

Evidence-based treatments for seasonal affective disorder (SAD) include light therapy and pharmacotherapy. We briefly review the diagnosis and treatment of SAD, focusing on clinical and treatment differences between patients with unipolar and bipolar illness. Special considerations for the management of SAD in patients with bipolar disorder are discussed, including the need to monitor for emergence of manic and hypomanic mood switches, to use mood stabilizers in patients with bipolar I disorder, and to be aware of potential interactions between bright light and medications used in treating bipolar disorder. Chronobiological treatments such as bright light therapy may be combined with pharmacotherapy to enhance therapeutic effects, reduce adverse side effects, and optimize treatment in patients with seasonal and nonseasonal bipolar disorder.

Treatment of seasonal affective disorders

Seasonal affective disorder (SAD) is a subform of major depressive disorder, recurrent, or bipolar disorder with a regular onset of depressive episodes at a certain time of year, usually the winter. The treatment of SAD is similar to that of other forms of affective disorder, except that bright light therapy is recommended as the first-line option. Light therapy conventionally involves exposure to visible light of at least 2500 lux intensity at eye level. The effects of light therapy are thought to be mediated exclusively by the eyes, not the skin, although this assumption has not yet been verified. Morning light therapy has proven to be superior to treatment regimens in the evening. Response rates to light therapy are about 80% in selected patient populations, with atypical depressive symptoms being the best predictor of a favorable treatment outcome. Data from randomized, controlled trials suggest that antidepressants are effective in the treatment of SAD. Three double-blind, placebo-controlled trials have been conducted showing promising results for the selective serotonin reuptake inhibitors (SSRIs) sertraline and fluoxetine, as well as for moclobemide, a reversible inhibitor of monoamine oxidase A.

The effect of dawn simulation on the cortisol response to awakening in healthy participants

Bright light exposure after awakening has been shown to elevate cortisol levels in healthy participants. The present study examined the effect of dawn simulation (a treatment for seasonal affective disorder) on the cortisol response to awakening and mood. Twelve healthy participants were supplied with a dawn simulator (The Natural Alarm Clock, Outside In, Cambridge Ltd), a bedside light that increases in intensity prior to awakening to approximately 250 lux over 30 mins when an audible alarm sounds. A counterbalanced study was performed on 4 consecutive normal weekdays, two of which were control days (no dawn simulation) and two experimental (dawn simulation). Saliva samples were taken immediately on awakening then at 15, 30 and 45 minutes post awakening on all 4 study-days. Total cortisol production during the first 45 mins after awakening was found to be significantly higher in the experimental condition than in the control condition. Participants also reported greater arousal in the experimental condition and there was a trend for an association between increased arousal and increased cortisol secretory activity under dawn simulation. This study provides supportive evidence for the role of light and the suprachiasmatic nucleus in the awakening cortisol response.

Cognitive-behavioral therapy, light therapy, and their combination in treating seasonal affective disorder

Background: The need to develop supplementary or alternative treatments for seasonal affective disorder (SAD) is underscored by the significant minority (47%) of SAD patients that is refractory to light therapy, the persistence of residual symptoms despite light treatment, and poor long-term compliance with light use. Because preliminary studies suggest that cognitive and behavioral factors are involved in SAD, cognitive-behavioral therapy (CBT) warrants investigation as a possible treatment option. Methods: We piloted a 6-week randomized clinical trial to compare a standard light therapy protocol; a novel, SAD-tailored, group CBT intervention; and their combination in ameliorating and remitting a current SAD episode and as prophylaxis against episode recurrence. Depressive symptom severity and remission rates were assessed at post-treatment and at a 1-year follow-up visit to examine long-term treatment durability. Results: CBT, light therapy, and their combination all demonstrated significant reductions in depressive symptoms on two different outcome measures. Remission rates varied by measure, but did not reach statistical significance. During the subsequent winter, CBT, particularly in combination with light therapy, appeared to improve long-term outcome regarding symptom severity, remission rates, and relapse rates. No CBT-treated participant, with or without light, experienced a full SAD relapse compared to over 60% of those treated with light alone. Limitations: These results should be viewed as preliminary and are limited by the small sample size ( n=23) and lack of a control group. Conclusions: The nearly half of SAD patients who do not remit with light alone may benefit from CBT as an adjunct or alternative treatment, especially as a prophylaxis against episode recurrence.

Aetiology and pathogenesis of mood disorders.

Seasonal affective disorder (SAD) was originally described as a syndrome in which depression developed during autumn or winter and remitted the following spring or summer.1,,2 Since then two subtypes of SAD have been defined in the scientific literature: winter SAD and summer SAD, the former being by far the more frequent.2,,3 Most winter SAD patients have ‘atypical’ depressive symptoms such as increased sleep duration, increased appetite and weight, and carbohydrate craving. Patients with winter SAD may experience a reversal of their winter symptoms in summer: mild hypomania, elevated mood, increased libido, social activity and energy, and decreased sleep requirements, appetite and weight. Seasonality, the tendency to experience seasonal changes in mood and behaviour, can be viewed as a dimension, ranging from those who show no seasonal changes to those who show more extreme changes with the seasons. Seasonal changes of mood and behaviour are common throughout the population.4–,6 A survey in the Washington area found that approximately 4% of the population have winter SAD and over 10% more have sub‐syndromal winter SAD.4 Some 27% of respondents reported that changes with the seasons were a problem for them. Another survey, in New York City, indicated approximately 6% with potential clinical severity, 18% reporting milder symptoms that were bothersome, and 35% noting symptoms but without complaint.6 Thus, many people experience mild analogues of winter SAD. A considerable number of studies by researchers around the world have demonstrated that light therapy (daily scheduled exposure to artificial light) is an effective treatment for winter SAD.1,6–,10 An internal pacemaker that matches internal rhythms to the 24‐h day drives circadian rhythms.9–,13 In humans, the master circadian pacemaker is the bilaterally paired suprachiasmatic nuclei (SCN) in the anterior hypothalamus. …