Evidence-Based Reviews

Seasonal affective disorder: How to help patients beat the winter blues

Current Psychiatry. 2002 December;1(12):13-17

References

1. Partonen T, Magnusson A. Seasonal affective disorder New York: Oxford University Press, 2001;3-134.

2. Lewy AJ, Kern HA, Rosenthal NE, Wehr TA. Bright artificial light treatment of a manic-depressive patient with a seasonal mood cycle. Am J Psychiatry 1982;139(11):1496-8.

3. Rosenthal NE, Sack DA, Gillin JC, et al. Seasonal affective disorder: A description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry 1984;41(1):72-80.

4. Rosenthal NE, Jacobsen FM, Sack DA, et al. Atenolol in seasonal affective disorder: a test of the melatonin hypothesis. Am J Psychiatry 1988;145:52-6.

5. Anderson JL, Rosen LN, Mendelson WB, et al. Sleep in fall/winter seasonal affective disorder: effects of light and changing seasons. J Psychosom Res 1994;38:323-37.

6. Reichborn-Kjennerud T, Lingjaerde O, Dahl AA. Personality disorders in patients with winter depression. Acta Psychiatrica Scand 1994;90:413-19.

7. Mersch PPA, Middendorp HM, Bouhuys AL, Beersma DGM, van den Hoofdakker RH. Seasonal affective disorder and latitude: a review of the literature. J Affect Disord 1999;53:35-48.

8. Wehr TA, Duncan WC, Sher L, et al. A circadian signal of change in patients with seasonal affective disorder. Arch Gen Psychiatry 2001;58:1108-14.

9. Lewy AJ, Sack RL, Singer CM, White DM, Hoban TM. Winter depression and the phase-shift hypothesis for bright light’s therapeutic effects: history, theory, and experimental evidence. J Biolog Rhythms 1988;3:121-34.

10. Avery DH, Kizer D, Bolte MA, Hellekson C. Bright light therapy of subsyndromal seasonal affective disorder in the workplace: morning vs. afternoon exposure. Acta Psychiatrica Scand 2000;103:267-74.

11. Sancar A. Cryptochrome: the second photoactive pigment in the eye and its role in circadian photoreception. Ann Rev Biochemistry 2000;69:31-67.

12. Meesters Y, Jansen JHC, Beersma DGM, Bouhuys AL, van den Hoofdakker RH. Light therapy for seasonal affective disorder: the effects of timing. Br J Psychiatry 1995;166:607-12.

13. Terman M. Internal night. Arch Gen Psychiatry 2001;58:1115-6.

14. Joffe RT, Moul DE, Lam RW, et al. Light visor treatment for seasonal affective disorder: a multicenter study. Psychiatry Res 1993;46(1):29-39.

15. Blashko CA, Moscovitch A, Eagles JM, Darcourt G, Thompson C, Kasper S. A placebo-controlled study of sertraline in the treatment of outpatients with seasonal affective disorder (unpublished data on file with Pfizer Inc.)

16. Thorell LH, Kjellman B, Arned M, Lindwall-Sundel K, Walinder J, Wetterberg L. Light treatment of seasonal affective disorder in combination with citalopram or placebo with 1-year follow-up. Int Clin Psychopharmacol 1999;14(suppl 2):S7-S11.

17. Hilger E. Reboxetine in seasonal affective disorder: an open trial. Eur Neuropsychopharmacology 2001;11(1):1-5.

Light therapy can be used alone or in addition to pharmacotherapy in patients whose previously wellcontrolled depressive symptoms worsen in the fall or winter. Light therapy also can be used as prophylaxis—starting in early fall—in patients with a history of a seasonal pattern of depression. Either way, light treatments generally should continue until early spring.

Given the relatively few side effects, light therapy may be used as monotherapy in patients with mild, subsyndromal mood symptoms occurring on a seasonal basis. Light therapy should not be used without pharmacotherapy to treat a full-blown major depressive episode.

Light boxes can be found via the Internet at an average cost of $180 to $300 for a 10,000-lux unit. The boxes are small enough to be placed on a table while the patient reads or eats breakfast. Artificial lights for this therapy do not emit ultraviolet rays, which have been associated with skin cancers.

Light visors also have shown some promise in SAD treatment, as demonstrated by a 2-week, randomized, controlled trial by Joffe et al.¹⁴ Compared with light boxes, light visors are more portable, so the patient can move around during treatment. Generally, the patient wears the visor 30 minutes in the morning.

Light visors appear to be as effective as table models, although no studies have compared the two devices. A visor costs $250 to $300.

Dawn simulation in SAD treatment has been examined in a few small studies and one placebo-controlled trial with 95 patients.¹⁰ In dawn simulation, a white light gradually increases between 4:30 and 6 AM to a peak intensity of 250 lux. Dawn simulation can be done while the patient is sleeping, whereas other light treatments require the patient to wake up early enough each morning to sit before a light box for 30 minutes. More study is needed to assess this modality’s efficacy.

Light therapy precautions. Review the patient’s medications before starting light therapy. Drugs that can magnify the effects of short wave-length light—leading to severe sunburns or rashes—include tetracycline, sulfonamides, and some older antipsychotics such as chlorpromazine. Some authors recommend an ophthalmologic examination before starting light therapy and every 2 to 3 years afterwards if no complications are apparent.¹ Others believe that no ophthalmologic examination is necessary unless the patient is older than 70 or has a history of retinal disease.

Side effects of bright light therapy are usually few and mild and include headaches, eye irritation, and nausea. In some anecdotal cases, patients with bipolar disorder appear to have switched from depression to mania upon starting light therapy,¹ but such switches appear to be rare. Still, patients with bipolar disorder and their family members should be advised to watch out for switches when using light therapy.

Pharmacologic therapy

Drug therapy in SAD has not been well studied, and many of the placebo-controlled trials that have examined this mode of treatment have been small. Serotonergic agents have been most studied because serotonin, with its effects on sleep and appetite, is thought to be related to SAD pathogenesis. The largest study of a selective serotonin reuptake inhibitor for SAD¹⁵ compared sertraline with placebo. Patients who received sertraline at a mean dosage of 111 mg/d had significantly fewer depressive symptoms than did the placebo group.

A placebo-controlled, double-blind study by Thorell¹⁶ found that adding citalopram to light therapy improved measures of depressed mood, compared with light therapy alone. This study is limited by small sample size but provides direction for further research.

An open trial of reboxetine—a noradrenaline reuptake inhibitor not available in the United States—suggests that further research of agents affecting catecholamines may be worthwhile in SAD treatment.¹⁷

Psychotherapy

Psychotherapy has not been researched sufficiently to be considered a proven treatment for SAD. However, some have observed that SAD patients have a negative cognitive style that may benefit from cognitive therapy. Thus, behavioral therapy may alter a patient’s response to light.¹

Related resources

National Organization for Seasonal Affective Disorder www.nosad.org
Dr. Ivan’s (Ivan Goldberg, MD) Depression Central www.psycom.net/depression.central.seasonal.html
Columbia/Presbyterian Hospital Program in Clinical Chronobiology www.light-and-iontherapy.org

Drug brand names

Citalopram • Celexa
Sertraline • Zoloft

Disclosure

Dr. Paradies reports no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

Dr. Hillard reports that he is a consultant to Pfizer Inc. and Janssen Pharmaceutica, and serves on the speakers bureau of Pfizer Inc., Janssen Pharmaceutica, and Eli Lilly and Co.