Seasonal affective disorder: Difference between revisions

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'''For patient information click [[Seasonal affective disorder (patient information)|here]]'''
'''For patient information click [[Seasonal affective disorder (patient information)|here]]'''


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   Image          = Bright light lamp.jpg|
   Image          = Bright light lamp.jpg|
   Caption        = Light therapy lamp for Seasonal Affective Disorder|
   Caption        = Light therapy lamp for the treatment of seasonal affective disorder (SAD)|
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{{SI}}
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{{CMG}}
 
{{CMG}}; {{AE}} {{Sharma}} ; {{HW}}
 
{{SK}} SAD, seasonal disorder, seasonal depression, winter blues, winter depression


==Overview==
==Overview==
'''Seasonal affective disorder''', also known as '''winter depression''', is an [[affective disorder|affective]], or [[mood disorder|mood]], [[mental illness|disorder]]. Most SAD sufferers experience normal mental health throughout most of the year, but experience [[depression (mood)|depressive]] symptoms in the winter or summer. The condition in the summer is often referred to as Reverse Seasonal Affective Disorder.  
Seasonal affective disorder (SAD), also known as winter depression, is a form of [[depression]] that is related to changes in the season. In the most common form of SAD, an individual experiences more frequent [[depressive]] periods between the late fall and early spring, with a return to normal baseline mood in the late spring and summer months. Less commonly, patients may experience [[depressive]] episodes in the summer; this type of disorder is known as reverse seasonal affective disorder (Reverse-SAD). The management options for SAD are [[phototherapy]], [[medications]], [[psychotherapy]], or a combination of these.
 
==Historical Perspective==
 
*The seasonal variation in mood is observed since ancient times.
*Hippocrates circa (400 BC) first explained seasonal [[depression]]. <ref name="Sher2000">{{cite journal|last1=Sher|first1=Leo|title=Seasonal Affective Disorder and Seasonality: A Review|journal=Jefferson Journal of Psychiatry|volume=15|issue=1|year=2000|issn=19350783|doi=10.29046/JJP.015.1.001}}</ref>
*The Greco-Roman physicians managed [[depression]] by focusing the sunlight toward the affected individual's eyes.<ref name="Sher2000">{{cite journal|last1=Sher|first1=Leo|title=Seasonal Affective Disorder and Seasonality: A Review|journal=Jefferson Journal of Psychiatry|volume=15|issue=1|year=2000|issn=19350783|doi=10.29046/JJP.015.1.001}}</ref>
*In 1894, Cook described a disorder characterized by [[depressed mood]], low energy, [[fatigue]], and loss of [[libido]], which Cook related to the seasonal loss of sunlight. <ref name="Sher2000">{{cite journal|last1=Sher|first1=Leo|title=Seasonal Affective Disorder and Seasonality: A Review|journal=Jefferson Journal of Psychiatry|volume=15|issue=1|year=2000|issn=19350783|doi=10.29046/JJP.015.1.001}}</ref>
*Esquirol(1845) and Kraplein (1921) also described the seasonal variability in the mood.<ref name="Sher2000">{{cite journal|last1=Sher|first1=Leo|title=Seasonal Affective Disorder and Seasonality: A Review|journal=Jefferson Journal of Psychiatry|volume=15|issue=1|year=2000|issn=19350783|doi=10.29046/JJP.015.1.001}}</ref>
*In the 1980s, SAD was systematically described for the first time and named by South African physician Normal Rosenthal. He noticed that he felt significantly less energetic during the winters and returned to his normal state during the spring.<ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref>
*In 1984, a paper was published based on Rosenthal's idea of treating [[depression]] with artificial light therapy. <ref name="Rosenthal1984">{{cite journal|last1=Rosenthal|first1=Norman E.|title=Seasonal Affective Disorder|journal=Archives of General Psychiatry|volume=41|issue=1|year=1984|pages=72|issn=0003-990X|doi=10.1001/archpsyc.1984.01790120076010}}</ref>
*Wehr's (1989) contribution in the form of a chapter in the book seasonal affective disorder and [[phototherapy]] is well-acknowledged. <ref name="Eagles2018">{{cite journal|last1=Eagles|first1=John M.|title=Seasonal affective disorder|journal=British Journal of Psychiatry|volume=182|issue=2|year=2018|pages=174–176|issn=0007-1250|doi=10.1192/bjp.182.2.174}}</ref>
*Wehr et al have also described a variant with the opposite pattern, [[depression]] in the summers and non-depressed phases in the winters. This condition is termed reverse-SAD.<ref name="RosenthalWehr1987">{{cite journal|last1=Rosenthal|first1=Norman E|last2=Wehr|first2=Thomas A|title=Seasonal Affective Disorders|journal=Psychiatric Annals|volume=17|issue=10|year=1987|pages=670–674|issn=0048-5713|doi=10.3928/0048-5713-19871001-10}}</ref>
*The Seasonal Pattern Assessment Questionnaire (SPAQ), developed by Rosenthal in 1984, is a self-administered screening tool for SAD.<ref name="pmid26688752" />
 
==Classification==
 
*First in 1984, Rosenthal  et  al. proposed a diagnostic criteria in the form of Seasonal Pattern Assessment Questionnaire (SPAQ).<ref name="Magnusson2000">{{cite journal|last1=Magnusson|first1=A.|title=An overview of epidemiological studies on seasonal affective disorder|journal=Acta Psychiatrica Scandinavica|volume=101|issue=3|year=2000|pages=176–184|issn=0001690X|doi=10.1034/j.1600-0447.2000.101003176.x}}</ref>
*Diagnostic criteria for SAD was included in [[DSM-III-R]] in 1987. <ref name="Magnusson2000">{{cite journal|last1=Magnusson|first1=A.|title=An overview of epidemiological studies on seasonal affective disorder|journal=Acta Psychiatrica Scandinavica|volume=101|issue=3|year=2000|pages=176–184|issn=0001690X|doi=10.1034/j.1600-0447.2000.101003176.x}}</ref>
*According to the [[Diagnostic and statistical manual of mental disorders|Diagnostic and Statistical Manual of Mental Disorders]] ([[Diagnostic and statistical manual of mental disorders|DSM]]), SAD does not exist as a separate [[Disorder (medicine)|disorder]].
*In [[DSM-5]], the seasonal variation in mood is mentioned as a specifier for both [[major depressive disorder]] (recurrent episodes) and [[bipolar disorder]] ([[bipolar I]] and [[bipolar II]]). <ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The [[International Classification of Diseases]], Tenth Edition ([[ICD]]-10) includes SAD under the category of [[recurrent depressive disorder]]. The characteristic of this condition is that the symptomatology appear in winter and remit during the spring season.<ref name="MagnussonPartonen2014">{{cite journal|last1=Magnusson|first1=Andres|last2=Partonen|first2=Timo|title=The Diagnosis, Symptomatology, and Epidemiology of Seasonal Affective Disorder|journal=CNS Spectrums|volume=10|issue=8|year=2014|pages=625–634|issn=1092-8529|doi=10.1017/S1092852900019593}}</ref>


==Pathophysiology==
==Pathophysiology==
Seasonal mood variations are believed to be related to light. An argument for this view is the effectiveness of bright light therapy.<ref name = "Lam">{{cite journal | last = Lam  |first = RW |coauthors = Levitt AJ, Levitan RD, Enns MW, Morehouse R, Michalak EE, Tam EM |title = The Can-SAD Study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder |journal = American Journal of Psychiatry |volume = 163 |issue = 5 |year = 2006 |page = 805-812 | accessdate = 2007-05-12 | id = 16648320 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16648320&query_hl=5&itool=pubmed_docsum }}</ref> SAD is measurably present at latitudes in the Arctic region, such as Finland (64º 00´N) where the rate of SAD is 9.5%<ref name = "Avery">{{cite journal | last = Avery |first = D H |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11513820&query_hl=14&itool=pubmed_docsum | coauthors = Eder DN, Bolte MA, Hellekson CJ, Dunner DL, Vitiello MV, Prinz PN |title =Dawn simulation and bright light in the treatment of SAD: a controlled study | journal = Biological Psychiatry |volume = 50 |issue = 3 |year = 2001 |pages = 205-216 = id = 11513820 | accessdate = 2007-05-05}}</ref> Cloud cover may contribute to the negative effects of SAD.<ref name = "Modell">{{cite journal |last = Modell |first = Jack |coauthors = Rosenthal NE, Harriett AE, Krishen A, Asgharian A, Foster VJ, Metz A, Rockett CB, Wightman DS |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16271314&query_hl=19&itool=pubmed_docsum |title = Seasonal affective disorder and its prevention by anticipatory treatment with bupropion XL Biological Psychiatry |volume = 58 |issue = 8 |year = 2005 |pages =  658-667 | id = 16271314}}</ref>


SAD can be a serious disorder and may require hospitalization. There is also potential risk of suicide in some patients experiencing SAD. One study reports 6-35% of sufferers required hospitalization during one period of illness.<ref name = "Modell"/> The symptoms of SAD mimic those of [[dysthymia]] or [[clinical depression]]. At times, patients may not feel depressed, but rather lack energy to perform everyday activities.<ref name = "Lam"/> Norman Rosenthal, a pioneer in SAD research, has estimated that the prevalence of SAD in the adult United States population is between about 1.5 percent (in Florida) and about 9 percent (in the northern US).<ref name = "Modell"/>
*The pathophysiologic basis of SAD is not completely understood.
*There is a combined effect of [[circadian]], [[neurotransmitter]], and [[genetic]] modulations.
*The [[circadian]] phase shift and retinal [[phototransduction]] of light are also hypothesized to be involved in the [[pathophysiology]].<ref name="pmid11109298">{{cite journal| author=Lam RW, Levitan RD| title=Pathophysiology of seasonal affective disorder: a review. | journal=J Psychiatry Neurosci | year= 2000 | volume= 25 | issue= 5 | pages= 469-80 | pmid=11109298 | doi= | pmc=1408021 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11109298  }} </ref>
*The individuals with SAD have some of the following [[hormonal]]/[[neurotransmitter]] imbalances:<ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref><ref name="pmid11109298">{{cite journal| author=Lam RW, Levitan RD| title=Pathophysiology of seasonal affective disorder: a review. | journal=J Psychiatry Neurosci | year= 2000 | volume= 25 | issue= 5 | pages= 469-80 | pmid=11109298 | doi= | pmc=1408021 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11109298  }} </ref>
 
#'''[[Serotonin]]:''' Studies have shown that individuals with winter-occurring SAD produce more [[serotonin]] transporter proteins in the winters than in the summers, causing the lesser effect of [[serotonin]] in winters.<ref name="pmid27540474">{{cite journal| author=De Felice LJ| title=A current view of serotonin transporters. | journal=F1000Res | year= 2016 | volume= 5 | issue=  | pages=  | pmid=27540474 | doi=10.12688/f1000research.8384.1 | pmc=4965693 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27540474  }}</ref><ref name="pmid11709063">{{cite journal| author=Haase J, Killian AM, Magnani F, Williams C| title=Regulation of the serotonin transporter by interacting proteins. | journal=Biochem Soc Trans | year= 2001 | volume= 29 | issue= Pt 6 | pages= 722-8 | pmid=11709063 | doi=10.1042/0300-5127:0290722 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11709063  }}</ref>
#'''[[Norepinephrine]]:''' [[Catecholamine]] levels are also found to be low in these patients.
#'''[[Melatonin]]:''' In the winters, as days become shorter, and periods of darkness increase. The levels of [[melatonin]] that is produced during the night increases. This interferes with the [[circadian rhythm]] and induces [[lethargy]].
#'''[[Vitamin D]]:''' Patients with SAD tend to have lower levels of [[vitamin D]] than controls. This deficiency plays a role in exacerbating [[depression]] through interference with [[serotonin]] action.<ref name="pmid20450340">{{cite journal| author=Penckofer S, Kouba J, Byrn M, Estwing Ferrans C| title=Vitamin D and depression: where is all the sunshine? | journal=Issues Ment Health Nurs | year= 2010 | volume= 31 | issue= 6 | pages= 385-93 | pmid=20450340 | doi=10.3109/01612840903437657 | pmc=2908269 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20450340  }}</ref>
 
==Differential Diagnosis==
SAD must be differentiated from diseases that present with similar symptoms, including:<ref name="pmid17111890">{{cite journal| author=Lurie SJ, Gawinski B, Pierce D, Rousseau SJ| title=Seasonal affective disorder. | journal=Am Fam Physician | year= 2006 | volume= 74 | issue= 9 | pages= 1521-4 | pmid=17111890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17111890  }} </ref><ref name="pmid2243888">{{cite journal| author=Stewart JW, Quitkin FM, Terman M, Terman JS| title=Is seasonal affective disorder a variant of atypical depression? Differential response to light therapy. | journal=Psychiatry Res | year= 1990 | volume= 33 | issue= 2 | pages= 121-8 | pmid=2243888 | doi=10.1016/0165-1781(90)90065-d | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2243888  }} </ref>
 
*[[Major depressive disorder]]
*[[Atypical depression]]
*[[Bipolar Disorder]]
*[[Hypothyroidism]]
*Seasonal occupational stressors
*Seasonal [[psychosocial]] stressors
 
==Epidemiology and Demographics==
 
*The [[prevalence]] of SAD ranges from 1.5% to 9%, depending on latitude.<ref name="pmid26558494">{{cite journal| author=Nussbaumer B, Kaminski-Hartenthaler A, Forneris CA, Morgan LC, Sonis JH, Gaynes BN et al.| title=Light therapy for preventing seasonal affective disorder. | journal=Cochrane Database Syst Rev | year= 2015 | volume=  | issue= 11 | pages= CD011269 | pmid=26558494 | doi=10.1002/14651858.CD011269.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26558494  }} </ref>
*A higher positive correlation has been found with latitude and [[prevalence]] of winter SAD. This finding is prominent in the age groups over 35 years.<ref name="RosenTargum1990">{{cite journal|last1=Rosen|first1=Leora N.|last2=Targum|first2=Steven D.|last3=Terman|first3=Michael|last4=Bryant|first4=Michael J.|last5=Hoffman|first5=Howard|last6=Kasper|first6=Siegfried F.|last7=Hamovit|first7=Joelle R.|last8=Docherty|first8=John P.|last9=Welch|first9=Betty|last10=Rosenthal|first10=Norman E.|title=Prevalence of seasonal affective disorder at four latitudes|journal=Psychiatry Research|volume=31|issue=2|year=1990|pages=131–144|issn=01651781|doi=10.1016/0165-1781(90)90116-M}}</ref>
 
===Age===
 
*The [[age of onset]] of SAD is generally between 18 and 30 years.<ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref>
*In most of the studies, SAD has been diagnosed in younger adults.<ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref><ref name="KaneLowis2016">{{cite journal|last1=Kane|first1=Anna|last2=Lowis|first2=Michael J.|title=Seasonal Affective Disorder and Personality, Age, and Gender|journal=South African Journal of Psychology|volume=29|issue=3|year=2016|pages=124–127|issn=0081-2463|doi=10.1177/008124639902900304}}</ref>
*Compared to high-school students, SAD is found to be less prominent in adults. Winter type SAD is related to latitude in adults whereas sociocultural factors play a role in adolescents.<ref name="ImaiKayukawa2003">{{cite journal|last1=Imai|first1=Makoto|last2=Kayukawa|first2=Yuhei|last3=Ohta|first3=Tatsuro|last4=Li|first4=Lan|last5=Nakagawa|first5=Takeo|title=Cross-regional survey of seasonal affective disorders in adults and high-school students in Japan|journal=Journal of Affective Disorders|volume=77|issue=2|year=2003|pages=127–133|issn=01650327|doi=10.1016/S0165-0327(02)00110-6}}</ref>
 
===Gender===
 
*SAD is more common in women as compared to men. Women are four times as likely as men to be diagnosed with SAD.<ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref><ref name="KaneLowis2016">{{cite journal|last1=Kane|first1=Anna|last2=Lowis|first2=Michael J.|title=Seasonal Affective Disorder and Personality, Age, and Gender|journal=South African Journal of Psychology|volume=29|issue=3|year=2016|pages=124–127|issn=0081-2463|doi=10.1177/008124639902900304}}</ref>
*The gender differences in SAD are the same as in non-seasonal [[depression]].
*For assessing the gender-based prevalence of SAD, importance should be given to case criteria such as diagnosis ([[Unipolar depression|unipolar]] vs. [[bipolar]]), and birth [[cohort]].<ref name="LuchtKasper1999">{{cite journal|last1=Lucht|first1=M. J.|last2=Kasper|first2=S.|title=Gender differences in seasonal affective disorder (SAD)|journal=Archives of Women's Mental Health|volume=2|issue=2|year=1999|pages=83–89|issn=1434-1816|doi=10.1007/s007370050040}}</ref>
 
===Race===
 
*SAD has no specific racial predilection.
 
==Risk Factors==
Risk factors for SAD include:<ref name="NIMH"> National Institute of Mental Health. “Seasonal Affective Disorder.” 2016. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml </ref><ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref><ref>{{cite journal|title=Prevalence of seasonal affective disorder in Alaska|journal=American Journal of Psychiatry|volume=149|issue=9|year=1992|pages=1176–1182|issn=0002-953X|doi=10.1176/ajp.149.9.1176}}</ref><ref name="Avery">{{cite journal | last = Avery |first = D H |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11513820&query_hl=14&itool=pubmed_docsum | coauthors = Eder DN, Bolte MA, Hellekson CJ, Dunner DL, Vitiello MV, Prinz PN |title =Dawn simulation and bright light in the treatment of SAD: a controlled study | journal = Biological Psychiatry |volume = 50 |issue = 3 |year = 2001 |pages = 205-216 = id = 11513820 | accessdate = 2007-05-05}}</ref> <ref name="Modell">{{cite journal |last = Modell |first = Jack |coauthors = Rosenthal NE, Harriett AE, Krishen A, Asgharian A, Foster VJ, Metz A, Rockett CB, Wightman DS |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16271314&query_hl=19&itool=pubmed_docsum |title = Seasonal affective disorder and its prevention by anticipatory treatment with bupropion XL Biological Psychiatry |volume = 58 |issue = 8 |year = 2005 |pages =  658-667 | id = 16271314}}</ref><ref name="SherGoldman1999">{{cite journal|last1=Sher|first1=Leo|last2=Goldman|first2=David|last3=Ozaki|first3=Norio|last4=Rosenthal|first4=Norman E|title=The role of genetic factors in the etiology of seasonal affective disorder and seasonality|journal=Journal of Affective Disorders|volume=53|issue=3|year=1999|pages=203–210|issn=01650327|doi=10.1016/S0165-0327(98)00194-3}}</ref><ref name="ImaiKayukawa2003">{{cite journal|last1=Imai|first1=Makoto|last2=Kayukawa|first2=Yuhei|last3=Ohta|first3=Tatsuro|last4=Li|first4=Lan|last5=Nakagawa|first5=Takeo|title=Cross-regional survey of seasonal affective disorders in adults and high-school students in Japan|journal=Journal of Affective Disorders|volume=77|issue=2|year=2003|pages=127–133|issn=01650327|doi=10.1016/S0165-0327(02)00110-6}}</ref>
 
*Female gender
*Age less than 40 years
*Higher latitude
*Family history of [[depression]]
*5-HTTLPR [[gene]] [[polymorphism]]
*Sociocultural factors (for adolescents)
 
==Screening==
 
*The Seasonal Health Questionnaire (SHQ) was found to be more [[Sensitivity|sensitive]] and [[Specificity (tests)|specific]] than SPAQ. It also had higher [[Positive predictive value|positive]] and [[Negative predictive value|negative predictive values]]. <ref name="ThompsonThompson2004">{{cite journal|last1=Thompson|first1=Chris|last2=Thompson|first2=Susan|last3=Smith|first3=Rachel|title=Prevalence of seasonal affective disorder in primary care; a comparison of the seasonal health questionnaire and the seasonal pattern assessment questionnaire|journal=Journal of Affective Disorders|volume=78|issue=3|year=2004|pages=219–226|issn=01650327|doi=10.1016/S0165-0327(02)00314-2}}</ref>
*Other [[screening]] tools that can be used are<ref name="pmid20495687">{{cite journal| author=Roecklein KA, Rohan KJ, Postolache TT| title=Is seasonal affective disorder a bipolar variant? | journal=Curr Psychiatr | year= 2010 | volume= 9 | issue= 2 | pages= 42-54 | pmid=20495687 | doi= | pmc=2874241 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20495687  }} </ref>
**Seasonal Pattern module of the Structured Clinical Interview for [[Diagnostic and statistical manual of mental disorders|DSM]] Disorders (SCID)
**[[Hypomania]] Interview Guide for Seasonal Affective Disorder (HIGH-SAD)
**Structured Interview Guide for the Hamilton [[Depression]] Rating Scale—Seasonal Affective Disorder
 
==Natural History, Complications, and Prognosis==
 
*SAD can be a very serious disorder and may require hospitalization.<ref name="Modell" />
*There is also a risk of [[suicide]] in some patients experiencing SAD.<ref name="PartonenL??nnqvist1998">{{cite journal|last1=Partonen|first1=Timo|last2=L??nnqvist|first2=Jouko|title=Seasonal Affective Disorder|journal=CNS Drugs|volume=9|issue=3|year=1998|pages=203–212|issn=1172-7047|doi=10.2165/00023210-199809030-00004}}</ref>
*The symptoms mimic those of [[clinical depression]], with seasonal variability.
*The [[prognosis]] of SAD is generally good. However, it has been observed that an index episode with a short duration and the illness course with high frequency showed a seasonal relapse pattern. <ref name="ThompsonRaheja2018">{{cite journal|last1=Thompson|first1=Christopher|last2=Raheja|first2=Sunil K.|last3=King|first3=Elizabeth A.|title=A Follow-up Study of Seasonal Affective Disorder|journal=British Journal of Psychiatry|volume=167|issue=3|year=2018|pages=380–384|issn=0007-1250|doi=10.1192/bjp.167.3.380}}</ref>
*If appropriate [[treatment]] is started early with [[phototherapy]], the [[prognosis]] is generally better in patients with predominant atypical symptoms than those having typical melancholic symptoms.<ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
 
==Comorbidities==
Commonly [[Comorbidity|comorbid]] conditions include:<ref name="pmid17111890">{{cite journal| author=Lurie SJ, Gawinski B, Pierce D, Rousseau SJ| title=Seasonal affective disorder. | journal=Am Fam Physician | year= 2006 | volume= 74 | issue= 9 | pages= 1521-4 | pmid=17111890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17111890  }} </ref>
 
*[[Major depressive disorder]]
*[[Bipolar disorder]]
*[[ADHD]]
*[[Alcoholism]]
*[[Eating disorders]]
*[[Hypothyroidism]]
 
==Diagnosis==
 
===Diagnostic Criteria===
A [[diagnosis]] of SAD is used for patients who meet all the criteria for [[major depression]] and have [[depression]] corresponding to the onset of specific seasons for a minimum duration of two years.<ref name="NIMH"> National Institute of Mental Health. “Seasonal Affective Disorder.” 2016. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml </ref><ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
 
===Symptoms===
General symptoms of [[major depression]] are:<ref name="NIMH"> National Institute of Mental Health. “Seasonal Affective Disorder.” 2016. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml </ref>
 
*Feeling [[depressed]]
*Feeling hopeless
*[[Lethargy]]
*Lack of interest in activities enjoyed earlier
*[[Insomnia|Having trouble sleeping]]
*Changes in [[appetite]] or weight
*Difficulty concentrating
*Frequent thoughts of death or [[suicide]]
 
Symptoms of winter-occurring SAD are:<ref name="NIMH"> National Institute of Mental Health. “Seasonal Affective Disorder.” 2016. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml </ref><ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref>
 
*[[Lethargy]]
*[[Hypersomnia]]
*[[Overeating]] and [[weight gain]]
*Craving [[Carbohydrate|carbohydrates]] and [[Sugar|sugars]]
*Social withdrawal
 
[[Symptom|Symptoms]] of summer-occurring SAD are:<ref name="NIMH"> National Institute of Mental Health. “Seasonal Affective Disorder.” 2016. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml </ref><ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref>
 
*The decreased [[appetite]] and [[weight loss]]
*[[Insomnia]]
*[[Agitation]] and restlessness
*[[Anxiety]]
*Episodes of violence
 
===Diagnostic and Statistical Manual of Mental Disorders (DSM)===
 
*[[Diagnostic and statistical manual of mental disorders|DSM]]-5 criteria for the diagnosis of SAD specifier requires <ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
**Two or more episodes fulfilling the [[Diagnostic and statistical manual of mental disorders|DSM]]-5 criteria of major depressive episode in [[bipolar I]], [[bipolar II]], or [[major depressive disorder]] (recurrent), with the last two episodes being consecutive.
**Onset and [[remission]] of episodes must occur in the same season.
**Seasonal episodes must outnumber the non-seasonal ones.
**Non-seasonal episodes should be absent over the last two episodes.
**Seasonal [[psychosocial]] stressors should be excluded.


Various [[etiologies]] have been suggested. One possibility is that SAD is related to a lack of [[serotonin]], and serotonin polymorphisms could play a role in SAD,<ref>{{cite journal |last =  Johansson |first = C | coauthors = Smedh C, Partonen T, Pekkarinen P, Paunio T, Ekholm J, Peltonen L,Lichtermann D, Palmgren J, Adolfsson R, Schalling M |title = Seasonal affective disorder and serotonin-related polymorphisms |journal = Neurobiology of Disease |volume =  8 |issue = 2 |year = 2001 |pages = 351-357 |accessdate = 2007-05-05 |  url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11300730&query_hl=12&itool=pubmed_docsum | id = 11300730 }}</ref> although this has been disputed.<ref>{{cite journal |last = Johansson |first = C |coauthors = Willeit M, Levitan R, Partonen T, Smedh C, Del Favero J, Bel Kacem S, Praschak-Rieder N,Neumeister A, Masellis M, Basile V, Zill P, Bondy B, Paunio T, Kasper S, Van Broeckhoven C, Nilsson LG,Lam R, Schalling M, Adolfsson R. |title = The serotonin transporter promoter repeat length polymorphism, seasonal affective disorder and seasonality |journal = Psychological Medicine |volume = 33 |issue = 5  |year = 2003 | pages = 785-792 |accessdate = 2007-05-05 |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12877393&query_hl=3&itool=pubmed_docsum| id = 12877393}}</ref> Another theory is that [[melatonin]] produced in the [[pineal gland]] is the primary cause since there are direct connections between the retina and the pineal gland. Mice incapable of synthesizing melatonin appear to express "depression-like" behaviors, melatonin receptor ligands produce an antidepressant-like effect<ref>{{cite journal |last = Uz |first = T |coauthors =Manev, H |title = Prolonged swim-test immobility of serotonin N-acetyltransferase (AANAT)-mutant mice |journal = Journal of Pineal Research |volume = 30 |year = 2001 |pages = 166-170 |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11316327&query_hl=8&itool=pubmed_docsum |id = 11316327}}</ref> Subsyndromal Seasonal Affective Disorder is a milder form of SAD experienced by an estimated 14.3% vs. 6.4% of the U.S. population.<ref name = "Avery2">{{cite journal |last = Avery | first = D. H. | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11328240&query_hl=10&itool=pubmed_docsum | id = 11328240 | coauthors = Kizer D, Bolte MA, Hellekson C |title = Bright light therapy of subsyndromal seasonal affective disorder in the workplace: morning vs. afternoon exposure |journal = Acta Psychiatrica Scandinavica |volume = 103  | issue = 4  |year = 2001 | pages  = 267-274 | accessdate =2007-05-12 }}</ref> The blue feeling experienced by both SAD and SSAD sufferers can usually be dampened or extinguished by exercise and increased outdoor activity, particularly on sunny days, resulting in increased solar exposure.<ref name = "Leppämäki">{{cite journal | last = Leppämäki |first = Sami |coauthors = Haukka J, Lonnqvist J, Partonen T | title = Drop-out and mood improvement: a randomised controlled trial with light exposure and physical exercise | journal =  BMC Psychiatry |volume = 4 |issue = 22 |year  = 2004 | id = 15306031 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15306031&query_hl=12&itool=pubmed_docsum |accessdate = 2007-05-12 }}</ref> Connections between human mood, as well as energy levels, and the seasons are well-documented, even in healthy individuals. Particularly in high latitudes (50°N or S) it is common for people to experience lower energy levels.<ref name = "Leppämäki"/>
===International Classification of Diseases, Tenth Edition (ICD-10)===


== Treatment ==
*ICD-10 does not include specific clinical guidelines for diagnosing SAD.
*Specific criteria are present in the research-version of ICD-10. These are <ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
**These criteria can be applied to affective disorders category F30-33, the episodes must fulfill the [[diagnostic criteria]] for major depression.
**Three or more affective episodes must occur within 90 days period of the year for 3 or more consecutive years.
**[[Remission]] also occurring within 90 days period of the year.
**Seasonal episodes outnumber the non-seasonal ones.


There are many different treatments for seasonal affective disorder, including [[light therapy|light therapies]], medication, and ionized-air reception. Bright light treatments are common, however as many as 19% of patients stop use because of the inconvenience.<ref name = "Avery"/> Specially designed light, many times brighter than normal office lighting, is placed near the sufferer, and has proven to be effective at doses of 2500- 10,000 [[lux]].<ref name = "Avery2"/> Most treatments use 30-60 minute treatments, however this varies depending on the situation. The sufferer sits a prescribed distance, commonly 30-60 cm, in front of the box with her/his eyes open but not staring at the light source.<ref name = "Avery"/> Many patients use the light box in the morning, however it has not been proven any more effective than any other time of day.<ref name = "Avery2"/> Discovering the best schedule is essential because up to 69% of patients find it inconvenient.<ref name = "Avery"/> [[Dawn simulation]] has also proven to be more effective in some studies, there is an 83% better response when compared to bright light.<ref name = "Avery"/> When compared in a study to negative air ionization however, bright light was proven to be 57.1% effective vs. dawn simulation, 49.5%.<ref name = "Terman">{{cite journal | last = Terman | first = M. |coauthors = Terman, J.S. | title = Controlled Trial of Naturalistic Dawn Simulation and Negative Air Ionization for Seasonal Affective Disorder | journal = American Journal of Psychiatry |volume  = 163 |issue = 12 |year = 2006 |pages = 2126-2133 | accessdate = 2007-05-12 |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17151164&query_hl=7&itool=pubmed_docsum |id = 17151164}}</ref> Patients using light therapy can experience improvement during the first week, but increased results are evident when continued throughout several weeks.<ref name = "Avery"/>  Most studies found it effective without use year round, but rather as a seasonal treatment lasting for several weeks until frequent light exposure is naturally obtained.<ref name = "Lam"/> [[SSRI]] (selective serotonin reuptake inhibitor) antidepressants have proven effective in treating SAD. [[Bupropion]] is also effective as a prophylactic.<ref name = "Modell"/> Effective antidepressants are [[fluoxetine]],  [[sertraline]], or [[paroxetine]].<ref name = "Lam"/><ref>{{cite journal |last = Moscovitch |first = A |url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14504682&query_hl=3&itool=pubmed_docsum | coauthors = Blashko CA, Eagles JM, Darcourt G, Thompson C, Kasper S, Lane RM |title = A placebo-controlled study of sertraline in the treatment of outpatients with seasonal affective disorder |journal =  Psychopharmacology |volume = 171 |year = 2004 |pages = 390-397 | accessdate = 2007-05-12}}</ref> Both fluoxetine and light therapy are 67% effective in treating SAD according to direct head-to-head trials.<ref name = "Lam"/> Negative air ionization, involving the release of charged particles into the sleep environment, has also been found effective with a 47.9% improvement.<ref name = "Terman"/> Depending upon the patient, one treatment (ie. lightbox) may be used in conjunction with another therapy (ie. medication).<ref name = "Lam"/>
==Treatment==


==Throughout the world==
*The main options for the [[treatment]] of SAD include [[light therapy]], [[medication]], and [[psychotherapy]].<ref name="pmid22033639">{{cite journal| author=Praschak-Rieder N, Willeit M| title=Treatment of seasonal affective disorders. | journal=Dialogues Clin Neurosci | year= 2003 | volume= 5 | issue= 4 | pages= 389-98 | pmid=22033639 | doi= | pmc=3181778 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22033639  }} </ref>
===Scandinavia===
*Any of these therapies can be used alone or in combination. Combination therapies are useful if the patient is unresponsive to a single [[treatment]] modality. <ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
''Winter depression'' (or ''winter blues'') is a common slump in the mood of Scandinavians. Doctors estimate that about 20% of all Swedes are affected, and it seems to be [[genetically]] heritable. It was first described by the 6th century Goth scholar Jordanes in his ''Getica'' where he described the inhabitants of Scandza (Scandinavia).<ref>Jordanes, ''Getica,'' ed. Mommsen, ''Mon. Germanae historica, V,'' Berlin, 1882.</ref> There are words in Icelandic and Swedish that directly describe Seasonal Affective conditions. The Icelandic word is "skammdegisthunglyndi." "Skamm" means short, "degi" is day, "thung" is heavy and "lyndi" means mood, although there is some argument as to how long the word existed as the earliest records indicate it appeared in the late 1800s in print. <ref>[http://www.seeingbeyondsad.com/history.html]</ref>


===United States===
====Light Therapy====
In the United States, a diagnosis of seasonal affective disorder was first proposed by Norman E. Rosenthal, MD in 1984. Rosenthal wondered why he became muggish during the winter after moving from sunny South Africa to New York. He started experimenting increasing exposure to artificial light, and found this made a difference. In Alaska it has been established that there is an SAD rate of 8.9%, and an even greater rate of 24.9% for subsyndromal SAD.<ref>[http://www.britebox-sad-lamps.com/sad-study-latitude.php Seasonal Affective Disorder and Latitude]</ref>


==SAD and bipolar disorder==
*SAD has been treated primarily with [[light therapy]]. It is also called bright light therapy (BLT) or [[phototherapy]].<ref name="NIMH"> National Institute of Mental Health. “Seasonal Affective Disorder.” 2016. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml </ref><ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref>
Most people with SAD experience unipolar depression, but as many as 20% may have or go on to develop a [[Bipolar disorder|bipolar]] or manic-depressive disorder. In these cases, people with SAD may experience depression during the winter and hypomania in the summer.<ref>[http://www.mooddisorderscanada.ca/depression/sad.htm SAD and depression]</ref>
*The rationale behind the use of [[light therapy]] is that the [[depressive]] effect of decreased sunlight during the winter months can be counteracted through daily exposure to bright light. [[Phototherapy]] acts through the change in the amplitude and timing of [[melatonin]] secretion as well as [[serotonergic]] system modulation. <ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
*Patients who undergo [[light therapy]] typically use a lightbox each morning from early fall until the start of spring.
*The use of lightboxes generally requires 20 to 60 minutes of exposure to 10,000 lux of cool-white [[fluorescent]] light, which is approximately 20 times brighter than the standard light.<ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
*Common side effects of light therapy include [[eye strain]], [[insomnia]], and [[headaches]].<ref>{{cite journal|title=Side effects of light therapy in seasonal affective disorder|journal=American Journal of Psychiatry|volume=150|issue=4|year=1993|pages=650–652|issn=0002-953X|doi=10.1176/ajp.150.4.650}}</ref>
*If patients experience side effects, the therapy should be split multiple times a day or administered earlier in the day in case of [[insomnia]]. <ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
*[[Light therapy]] is contraindicated if the patient is on photosensitizing medications.<ref name="pmid26688752">{{cite journal| author=Melrose S| title=Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. | journal=Depress Res Treat | year= 2015 | volume= 2015 | issue=  | pages= 178564 | pmid=26688752 | doi=10.1155/2015/178564 | pmc=4673349 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26688752  }} </ref>
*[[Light therapy]] is used daily and it may take up to two weeks for the complete [[therapeutic]] response. Maintenance treatment is usually needed daily for the rest of the winter. The treatment should be discontinued on [[remission]] otherwise may result in [[hypomania]].<ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
*Precipitation of [[hypomanic]] episodes with phototherapy is commonly seen with [[bipolar]] cases. These can be controlled by reducing the therapy dose.<ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
*Patients with atypical symptoms of [[depression]] respond better to [[light therapy]]. <ref name="Terman1989">{{cite journal|last1=Terman|first1=M|title=Light therapy for Seasonal Affective Disorder A review of efficacy|journal=Neuropsychopharmacology|volume=2|issue=1|year=1989|pages=1–22|issn=0893133X|doi=10.1016/0893-133X(89)90002-X}}</ref>


==See also==
====Medications====
* [[Depression (mood)]]
* [[Circadian rhythm sleep disorder]]


==References==
*SAD may be treated with [[selective serotonin reuptake inhibitors]] ([[Selective serotonin reuptake inhibitor|SSRIs]]) such as [[sertraline]], and [[fluoxetine]]. Like [[phototherapy]], [[SSRIs]] should be discontinued on remission to avoid [[hypomania]]. <ref name="RodinThompson2018">{{cite journal|last1=Rodin|first1=I.|last2=Thompson|first2=C.|title=Seasonal affective disorder|journal=Advances in Psychiatric Treatment|volume=3|issue=6|year=2018|pages=352–359|issn=1355-5146|doi=10.1192/apt.3.6.352}}</ref>
{[reflist|2}}
*Common [[side effects]] of [[SSRIs]] are [[nausea]], [[diarrhea]], [[constipation]], [[vomiting]], [[dry mouth]], weight changes, sexual dysfunction,  and [[headaches]].<ref name="pmid19724743">{{cite journal| author=Cascade E, Kalali AH, Kennedy SH| title=Real-World Data on SSRI Antidepressant Side Effects. | journal=Psychiatry (Edgmont) | year= 2009 | volume= 6 | issue= 2 | pages= 16-8 | pmid=19724743 | doi= | pmc=2719451 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19724743  }} </ref>
*[[Bupropion]], a norepinephrine dopamine reuptake inhibitor ([[NDRI]]), has been specifically approved by the [[FDA]] for the treatment of SAD. It can also be used prophylactically in these patients to prevent another episode. <ref name="ModellRosenthal2005">{{cite journal|last1=Modell|first1=Jack G.|last2=Rosenthal|first2=Norman E.|last3=Harriett|first3=April E.|last4=Krishen|first4=Alok|last5=Asgharian|first5=Afsaneh|last6=Foster|first6=Vicki J.|last7=Metz|first7=Alan|last8=Rockett|first8=Carol B.|last9=Wightman|first9=Donna S.|title=Seasonal Affective Disorder and Its Prevention by Anticipatory Treatment with Bupropion XL|journal=Biological Psychiatry|volume=58|issue=8|year=2005|pages=658–667|issn=00063223|doi=10.1016/j.biopsych.2005.07.021}}</ref>
*Common side effects of [[bupropion]] are [[drowsiness]], [[anxiety]], [[insomnia]], [[dry mouth]], [[dizziness]], [[weight loss]], and [[sore throat]].<ref name="Wilkes2006">{{cite journal|last1=Wilkes|first1=S.|title=Bupropion|journal=Drugs of Today|volume=42|issue=10|year=2006|pages=671|issn=1699-3993|doi=10.1358/dot.2006.42.10.1025701}}</ref>
*Although studies have variable results with the use of [[vitamin D]] in patients with SAD, researchers have postulated that it may be helpful due to low [[vitamin D]] levels in these patients.<ref name="pmid10888476">{{cite journal| author=Gloth FM, Alam W, Hollis B| title=Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder. | journal=J Nutr Health Aging | year= 1999 | volume= 3 | issue= 1 | pages= 5-7 | pmid=10888476 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10888476  }} </ref>
*[[Agomelatine]] (melatonergic (MT1 and MT2) receptor agonist and [[serotonin]]-2C receptor antagonist) has also shown improvement in SAD symptomatology.<ref name="PjrekWinkler2006">{{cite journal|last1=Pjrek|first1=Edda|last2=Winkler|first2=Dietmar|last3=Konstantinidis|first3=Anastasios|last4=Willeit|first4=Matthäus|last5=Praschak-Rieder|first5=Nicole|last6=Kasper|first6=Siegfried|title=Agomelatine in the treatment of seasonal affective disorder|journal=Psychopharmacology|volume=190|issue=4|year=2006|pages=575–579|issn=0033-3158|doi=10.1007/s00213-006-0645-3}}</ref>
*Other treatment modalities with limited evidence in the management of seasonal affective disorder are high-density negative ionizer, [[Moclobemide]] ([[Monoamine oxidase A|Monoamine oxidase A Inhibitor]]), [[Duloxetine]] ([[Serotonin-norepinephrine reuptake inhibitor|Serotonin Norepinephrine Reuptake Inhibitor]]), [[Modafinil]], and hypericum extract.  <ref name="TermanTerman1995">{{cite journal|last1=Terman|first1=Michael|last2=Terman|first2=Jiuan Su|title=Treatment of Seasonal Affective Disorder with a High-Output Negative Ionizer|journal=The Journal of Alternative and Complementary Medicine|volume=1|issue=1|year=1995|pages=87–92|issn=1075-5535|doi=10.1089/acm.1995.1.87}}</ref><ref name="Partonen1996">{{cite journal|last1=Partonen|first1=T|title=Moclobemide and fluoxetine in treatment of seasonal affective disorder|journal=Journal of Affective Disorders|volume=41|issue=2|year=1996|pages=93–99|issn=01650327|doi=10.1016/S0165-0327(96)00073-0}}</ref><ref name="Kasper2007">{{cite journal|last1=Kasper|first1=S.|title=Treatment of Seasonal Affective Disorder (SAD) with Hypericum Extract|journal=Pharmacopsychiatry|volume=30|issue=S 2|year=2007|pages=89–93|issn=0176-3679|doi=10.1055/s-2007-979526}}</ref><ref name="PjrekWilleit2008">{{cite journal|last1=Pjrek|first1=E.|last2=Willeit|first2=M.|last3=Praschak-Rieder|first3=N.|last4=Konstantinidis|first4=A.|last5=Semlitsch|first5=H.|last6=Kasper|first6=S.|last7=Winkler|first7=D.|title=Treatment of Seasonal Affective Disorder with Duloxetine: An Open-Label Study|journal=Pharmacopsychiatry|volume=41|issue=3|year=2008|pages=100–105|issn=0176-3679|doi=10.1055/s-2008-1058103}}</ref><ref name="Lundt2004">{{cite journal|last1=Lundt|first1=L|title=Modafinil treatment in patients with seasonal affective disorder/winter depression: an open-label pilot study|journal=Journal of Affective Disorders|volume=81|issue=2|year=2004|pages=173–178|issn=01650327|doi=10.1016/S0165-0327(03)00162-9}}</ref>
 
====Psychotherapy====


[[de:Winterdepression]]
*The use of [[psychotherapy]], specifically [[cognitive behavioral therapy]] ([[Cognitive-behavioral therapy|CBT]]), to treat SAD is common.
[[he:דיכאון עונתי]]
*[[Cognitive-behavioral therapy|CBT]], in combination with light therapy, has shown promising results. <ref name="RohanRoecklein2007">{{cite journal|last1=Rohan|first1=Kelly J.|last2=Roecklein|first2=Kathryn A.|last3=Tierney Lindsey|first3=Kathryn|last4=Johnson|first4=Leigh G.|last5=Lippy|first5=Robert D.|last6=Lacy|first6=Timothy J.|last7=Barton|first7=Franca B.|title=A randomized controlled trial of cognitive-behavioral therapy, [[light therapy]], and their combination for seasonal affective disorder.|journal=Journal of Consulting and Clinical Psychology|volume=75|issue=3|year=2007|pages=489–500|issn=1939-2117|doi=10.1037/0022-006X.75.3.489}}</ref>
[[nl:winterdepressie]]
*The use of [[psychotherapy]] for the prevention of a new [[depressive]] episode in individuals with a history of SAD is inconclusive. <ref name="FornerisNussbaumer-Streit2019">{{cite journal|last1=Forneris|first1=Catherine A|last2=Nussbaumer-Streit|first2=Barbara|last3=Morgan|first3=Laura C|last4=Greenblatt|first4=Amy|last5=Van Noord|first5=Megan G|last6=Gaynes|first6=Bradley N|last7=Wipplinger|first7=Jörg|last8=Lux|first8=Linda J|last9=Winkler|first9=Dietmar|last10=Gartlehner|first10=Gerald|title=Psychological therapies for preventing seasonal affective disorder|journal=Cochrane Database of Systematic Reviews|year=2019|issn=14651858|doi=10.1002/14651858.CD011270.pub3}}</ref>
[[ja:季節性情動障害]]
[[no:Sesongavhengig depresjon]]
[[pl:Depresja zimowa]]
[[fi:Kaamosmasennus]]
[[sv:Årstidsbunden depression]]
[[zh:季节性情绪失调]]


* Seasonal affective disorder is surrounded by [[treatment]] options with inadequate evidence. The [[prophylaxis]] and management measures warrant thorough long-term research to optimize patient well-being.


==References==
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[[Category:Psychiatry]]
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[[Category: Up-To-Date]]

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Seasonal affective disorder
Light therapy lamp for the treatment of seasonal affective disorder (SAD)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2] ; Haleigh Williams, B.S.

Synonyms and keywords: SAD, seasonal disorder, seasonal depression, winter blues, winter depression

Overview

Seasonal affective disorder (SAD), also known as winter depression, is a form of depression that is related to changes in the season. In the most common form of SAD, an individual experiences more frequent depressive periods between the late fall and early spring, with a return to normal baseline mood in the late spring and summer months. Less commonly, patients may experience depressive episodes in the summer; this type of disorder is known as reverse seasonal affective disorder (Reverse-SAD). The management options for SAD are phototherapy, medications, psychotherapy, or a combination of these.

Historical Perspective

  • The seasonal variation in mood is observed since ancient times.
  • Hippocrates circa (400 BC) first explained seasonal depression. [1]
  • The Greco-Roman physicians managed depression by focusing the sunlight toward the affected individual's eyes.[1]
  • In 1894, Cook described a disorder characterized by depressed mood, low energy, fatigue, and loss of libido, which Cook related to the seasonal loss of sunlight. [1]
  • Esquirol(1845) and Kraplein (1921) also described the seasonal variability in the mood.[1]
  • In the 1980s, SAD was systematically described for the first time and named by South African physician Normal Rosenthal. He noticed that he felt significantly less energetic during the winters and returned to his normal state during the spring.[2]
  • In 1984, a paper was published based on Rosenthal's idea of treating depression with artificial light therapy. [3]
  • Wehr's (1989) contribution in the form of a chapter in the book seasonal affective disorder and phototherapy is well-acknowledged. [4]
  • Wehr et al have also described a variant with the opposite pattern, depression in the summers and non-depressed phases in the winters. This condition is termed reverse-SAD.[5]
  • The Seasonal Pattern Assessment Questionnaire (SPAQ), developed by Rosenthal in 1984, is a self-administered screening tool for SAD.[2]

Classification

Pathophysiology

  1. Serotonin: Studies have shown that individuals with winter-occurring SAD produce more serotonin transporter proteins in the winters than in the summers, causing the lesser effect of serotonin in winters.[10][11]
  2. Norepinephrine: Catecholamine levels are also found to be low in these patients.
  3. Melatonin: In the winters, as days become shorter, and periods of darkness increase. The levels of melatonin that is produced during the night increases. This interferes with the circadian rhythm and induces lethargy.
  4. Vitamin D: Patients with SAD tend to have lower levels of vitamin D than controls. This deficiency plays a role in exacerbating depression through interference with serotonin action.[12]

Differential Diagnosis

SAD must be differentiated from diseases that present with similar symptoms, including:[13][14]

Epidemiology and Demographics

  • The prevalence of SAD ranges from 1.5% to 9%, depending on latitude.[15]
  • A higher positive correlation has been found with latitude and prevalence of winter SAD. This finding is prominent in the age groups over 35 years.[16]

Age

  • The age of onset of SAD is generally between 18 and 30 years.[2]
  • In most of the studies, SAD has been diagnosed in younger adults.[2][17]
  • Compared to high-school students, SAD is found to be less prominent in adults. Winter type SAD is related to latitude in adults whereas sociocultural factors play a role in adolescents.[18]

Gender

  • SAD is more common in women as compared to men. Women are four times as likely as men to be diagnosed with SAD.[2][17]
  • The gender differences in SAD are the same as in non-seasonal depression.
  • For assessing the gender-based prevalence of SAD, importance should be given to case criteria such as diagnosis (unipolar vs. bipolar), and birth cohort.[19]

Race

  • SAD has no specific racial predilection.

Risk Factors

Risk factors for SAD include:[20][2][21][22] [23][24][18]

  • Female gender
  • Age less than 40 years
  • Higher latitude
  • Family history of depression
  • 5-HTTLPR gene polymorphism
  • Sociocultural factors (for adolescents)

Screening

  • The Seasonal Health Questionnaire (SHQ) was found to be more sensitive and specific than SPAQ. It also had higher positive and negative predictive values. [25]
  • Other screening tools that can be used are[26]
    • Seasonal Pattern module of the Structured Clinical Interview for DSM Disorders (SCID)
    • Hypomania Interview Guide for Seasonal Affective Disorder (HIGH-SAD)
    • Structured Interview Guide for the Hamilton Depression Rating Scale—Seasonal Affective Disorder

Natural History, Complications, and Prognosis

  • SAD can be a very serious disorder and may require hospitalization.[23]
  • There is also a risk of suicide in some patients experiencing SAD.[27]
  • The symptoms mimic those of clinical depression, with seasonal variability.
  • The prognosis of SAD is generally good. However, it has been observed that an index episode with a short duration and the illness course with high frequency showed a seasonal relapse pattern. [28]
  • If appropriate treatment is started early with phototherapy, the prognosis is generally better in patients with predominant atypical symptoms than those having typical melancholic symptoms.[29]

Comorbidities

Commonly comorbid conditions include:[13]

Diagnosis

Diagnostic Criteria

A diagnosis of SAD is used for patients who meet all the criteria for major depression and have depression corresponding to the onset of specific seasons for a minimum duration of two years.[20][7]

Symptoms

General symptoms of major depression are:[20]

Symptoms of winter-occurring SAD are:[20][2]

Symptoms of summer-occurring SAD are:[20][2]

Diagnostic and Statistical Manual of Mental Disorders (DSM)

  • DSM-5 criteria for the diagnosis of SAD specifier requires [29]
    • Two or more episodes fulfilling the DSM-5 criteria of major depressive episode in bipolar I, bipolar II, or major depressive disorder (recurrent), with the last two episodes being consecutive.
    • Onset and remission of episodes must occur in the same season.
    • Seasonal episodes must outnumber the non-seasonal ones.
    • Non-seasonal episodes should be absent over the last two episodes.
    • Seasonal psychosocial stressors should be excluded.

International Classification of Diseases, Tenth Edition (ICD-10)

  • ICD-10 does not include specific clinical guidelines for diagnosing SAD.
  • Specific criteria are present in the research-version of ICD-10. These are [29]
    • These criteria can be applied to affective disorders category F30-33, the episodes must fulfill the diagnostic criteria for major depression.
    • Three or more affective episodes must occur within 90 days period of the year for 3 or more consecutive years.
    • Remission also occurring within 90 days period of the year.
    • Seasonal episodes outnumber the non-seasonal ones.

Treatment

Light Therapy

  • SAD has been treated primarily with light therapy. It is also called bright light therapy (BLT) or phototherapy.[20][2]
  • The rationale behind the use of light therapy is that the depressive effect of decreased sunlight during the winter months can be counteracted through daily exposure to bright light. Phototherapy acts through the change in the amplitude and timing of melatonin secretion as well as serotonergic system modulation. [29]
  • Patients who undergo light therapy typically use a lightbox each morning from early fall until the start of spring.
  • The use of lightboxes generally requires 20 to 60 minutes of exposure to 10,000 lux of cool-white fluorescent light, which is approximately 20 times brighter than the standard light.[29]
  • Common side effects of light therapy include eye strain, insomnia, and headaches.[31]
  • If patients experience side effects, the therapy should be split multiple times a day or administered earlier in the day in case of insomnia. [29]
  • Light therapy is contraindicated if the patient is on photosensitizing medications.[2]
  • Light therapy is used daily and it may take up to two weeks for the complete therapeutic response. Maintenance treatment is usually needed daily for the rest of the winter. The treatment should be discontinued on remission otherwise may result in hypomania.[29]
  • Precipitation of hypomanic episodes with phototherapy is commonly seen with bipolar cases. These can be controlled by reducing the therapy dose.[29]
  • Patients with atypical symptoms of depression respond better to light therapy. [32]

Medications

Psychotherapy

  • Seasonal affective disorder is surrounded by treatment options with inadequate evidence. The prophylaxis and management measures warrant thorough long-term research to optimize patient well-being.

References

  1. 1.0 1.1 1.2 1.3 Sher, Leo (2000). "Seasonal Affective Disorder and Seasonality: A Review". Jefferson Journal of Psychiatry. 15 (1). doi:10.29046/JJP.015.1.001. ISSN 1935-0783.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Melrose S (2015). "Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches". Depress Res Treat. 2015: 178564. doi:10.1155/2015/178564. PMC 4673349. PMID 26688752.
  3. Rosenthal, Norman E. (1984). "Seasonal Affective Disorder". Archives of General Psychiatry. 41 (1): 72. doi:10.1001/archpsyc.1984.01790120076010. ISSN 0003-990X.
  4. Eagles, John M. (2018). "Seasonal affective disorder". British Journal of Psychiatry. 182 (2): 174–176. doi:10.1192/bjp.182.2.174. ISSN 0007-1250.
  5. Rosenthal, Norman E; Wehr, Thomas A (1987). "Seasonal Affective Disorders". Psychiatric Annals. 17 (10): 670–674. doi:10.3928/0048-5713-19871001-10. ISSN 0048-5713.
  6. 6.0 6.1 Magnusson, A. (2000). "An overview of epidemiological studies on seasonal affective disorder". Acta Psychiatrica Scandinavica. 101 (3): 176–184. doi:10.1034/j.1600-0447.2000.101003176.x. ISSN 0001-690X.
  7. 7.0 7.1 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  8. Magnusson, Andres; Partonen, Timo (2014). "The Diagnosis, Symptomatology, and Epidemiology of Seasonal Affective Disorder". CNS Spectrums. 10 (8): 625–634. doi:10.1017/S1092852900019593. ISSN 1092-8529.
  9. 9.0 9.1 Lam RW, Levitan RD (2000). "Pathophysiology of seasonal affective disorder: a review". J Psychiatry Neurosci. 25 (5): 469–80. PMC 1408021. PMID 11109298.
  10. De Felice LJ (2016). "A current view of serotonin transporters". F1000Res. 5. doi:10.12688/f1000research.8384.1. PMC 4965693. PMID 27540474.
  11. Haase J, Killian AM, Magnani F, Williams C (2001). "Regulation of the serotonin transporter by interacting proteins". Biochem Soc Trans. 29 (Pt 6): 722–8. doi:10.1042/0300-5127:0290722. PMID 11709063.
  12. Penckofer S, Kouba J, Byrn M, Estwing Ferrans C (2010). "Vitamin D and depression: where is all the sunshine?". Issues Ment Health Nurs. 31 (6): 385–93. doi:10.3109/01612840903437657. PMC 2908269. PMID 20450340.
  13. 13.0 13.1 Lurie SJ, Gawinski B, Pierce D, Rousseau SJ (2006). "Seasonal affective disorder". Am Fam Physician. 74 (9): 1521–4. PMID 17111890.
  14. Stewart JW, Quitkin FM, Terman M, Terman JS (1990). "Is seasonal affective disorder a variant of atypical depression? Differential response to light therapy". Psychiatry Res. 33 (2): 121–8. doi:10.1016/0165-1781(90)90065-d. PMID 2243888.
  15. Nussbaumer B, Kaminski-Hartenthaler A, Forneris CA, Morgan LC, Sonis JH, Gaynes BN; et al. (2015). "Light therapy for preventing seasonal affective disorder". Cochrane Database Syst Rev (11): CD011269. doi:10.1002/14651858.CD011269.pub2. PMID 26558494.
  16. Rosen, Leora N.; Targum, Steven D.; Terman, Michael; Bryant, Michael J.; Hoffman, Howard; Kasper, Siegfried F.; Hamovit, Joelle R.; Docherty, John P.; Welch, Betty; Rosenthal, Norman E. (1990). "Prevalence of seasonal affective disorder at four latitudes". Psychiatry Research. 31 (2): 131–144. doi:10.1016/0165-1781(90)90116-M. ISSN 0165-1781.
  17. 17.0 17.1 Kane, Anna; Lowis, Michael J. (2016). "Seasonal Affective Disorder and Personality, Age, and Gender". South African Journal of Psychology. 29 (3): 124–127. doi:10.1177/008124639902900304. ISSN 0081-2463.
  18. 18.0 18.1 Imai, Makoto; Kayukawa, Yuhei; Ohta, Tatsuro; Li, Lan; Nakagawa, Takeo (2003). "Cross-regional survey of seasonal affective disorders in adults and high-school students in Japan". Journal of Affective Disorders. 77 (2): 127–133. doi:10.1016/S0165-0327(02)00110-6. ISSN 0165-0327.
  19. Lucht, M. J.; Kasper, S. (1999). "Gender differences in seasonal affective disorder (SAD)". Archives of Women's Mental Health. 2 (2): 83–89. doi:10.1007/s007370050040. ISSN 1434-1816.
  20. 20.0 20.1 20.2 20.3 20.4 20.5 National Institute of Mental Health. “Seasonal Affective Disorder.” 2016. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml
  21. "Prevalence of seasonal affective disorder in Alaska". American Journal of Psychiatry. 149 (9): 1176–1182. 1992. doi:10.1176/ajp.149.9.1176. ISSN 0002-953X.
  22. Avery, D H (2001). "Dawn simulation and bright light in the treatment of SAD: a controlled study". Biological Psychiatry. 50 (3): 205-216 = id = 11513820. Retrieved 2007-05-05. Unknown parameter |coauthors= ignored (help)
  23. 23.0 23.1 Modell, Jack (2005). "Seasonal affective disorder and its prevention by anticipatory treatment with bupropion XL Biological Psychiatry". 58 (8): 658–667. 16271314. Unknown parameter |coauthors= ignored (help)
  24. Sher, Leo; Goldman, David; Ozaki, Norio; Rosenthal, Norman E (1999). "The role of genetic factors in the etiology of seasonal affective disorder and seasonality". Journal of Affective Disorders. 53 (3): 203–210. doi:10.1016/S0165-0327(98)00194-3. ISSN 0165-0327.
  25. Thompson, Chris; Thompson, Susan; Smith, Rachel (2004). "Prevalence of seasonal affective disorder in primary care; a comparison of the seasonal health questionnaire and the seasonal pattern assessment questionnaire". Journal of Affective Disorders. 78 (3): 219–226. doi:10.1016/S0165-0327(02)00314-2. ISSN 0165-0327.
  26. Roecklein KA, Rohan KJ, Postolache TT (2010). "Is seasonal affective disorder a bipolar variant?". Curr Psychiatr. 9 (2): 42–54. PMC 2874241. PMID 20495687.
  27. Partonen, Timo; L??nnqvist, Jouko (1998). "Seasonal Affective Disorder". CNS Drugs. 9 (3): 203–212. doi:10.2165/00023210-199809030-00004. ISSN 1172-7047.
  28. Thompson, Christopher; Raheja, Sunil K.; King, Elizabeth A. (2018). "A Follow-up Study of Seasonal Affective Disorder". British Journal of Psychiatry. 167 (3): 380–384. doi:10.1192/bjp.167.3.380. ISSN 0007-1250.
  29. 29.0 29.1 29.2 29.3 29.4 29.5 29.6 29.7 29.8 29.9 Rodin, I.; Thompson, C. (2018). "Seasonal affective disorder". Advances in Psychiatric Treatment. 3 (6): 352–359. doi:10.1192/apt.3.6.352. ISSN 1355-5146.
  30. Praschak-Rieder N, Willeit M (2003). "Treatment of seasonal affective disorders". Dialogues Clin Neurosci. 5 (4): 389–98. PMC 3181778. PMID 22033639.
  31. "Side effects of light therapy in seasonal affective disorder". American Journal of Psychiatry. 150 (4): 650–652. 1993. doi:10.1176/ajp.150.4.650. ISSN 0002-953X.
  32. Terman, M (1989). "Light therapy for Seasonal Affective Disorder A review of efficacy". Neuropsychopharmacology. 2 (1): 1–22. doi:10.1016/0893-133X(89)90002-X. ISSN 0893-133X.
  33. Cascade E, Kalali AH, Kennedy SH (2009). "Real-World Data on SSRI Antidepressant Side Effects". Psychiatry (Edgmont). 6 (2): 16–8. PMC 2719451. PMID 19724743.
  34. Modell, Jack G.; Rosenthal, Norman E.; Harriett, April E.; Krishen, Alok; Asgharian, Afsaneh; Foster, Vicki J.; Metz, Alan; Rockett, Carol B.; Wightman, Donna S. (2005). "Seasonal Affective Disorder and Its Prevention by Anticipatory Treatment with Bupropion XL". Biological Psychiatry. 58 (8): 658–667. doi:10.1016/j.biopsych.2005.07.021. ISSN 0006-3223.
  35. Wilkes, S. (2006). "Bupropion". Drugs of Today. 42 (10): 671. doi:10.1358/dot.2006.42.10.1025701. ISSN 1699-3993.
  36. Gloth FM, Alam W, Hollis B (1999). "Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder". J Nutr Health Aging. 3 (1): 5–7. PMID 10888476.
  37. Pjrek, Edda; Winkler, Dietmar; Konstantinidis, Anastasios; Willeit, Matthäus; Praschak-Rieder, Nicole; Kasper, Siegfried (2006). "Agomelatine in the treatment of seasonal affective disorder". Psychopharmacology. 190 (4): 575–579. doi:10.1007/s00213-006-0645-3. ISSN 0033-3158.
  38. Terman, Michael; Terman, Jiuan Su (1995). "Treatment of Seasonal Affective Disorder with a High-Output Negative Ionizer". The Journal of Alternative and Complementary Medicine. 1 (1): 87–92. doi:10.1089/acm.1995.1.87. ISSN 1075-5535.
  39. Partonen, T (1996). "Moclobemide and fluoxetine in treatment of seasonal affective disorder". Journal of Affective Disorders. 41 (2): 93–99. doi:10.1016/S0165-0327(96)00073-0. ISSN 0165-0327.
  40. Kasper, S. (2007). "Treatment of Seasonal Affective Disorder (SAD) with Hypericum Extract". Pharmacopsychiatry. 30 (S 2): 89–93. doi:10.1055/s-2007-979526. ISSN 0176-3679.
  41. Pjrek, E.; Willeit, M.; Praschak-Rieder, N.; Konstantinidis, A.; Semlitsch, H.; Kasper, S.; Winkler, D. (2008). "Treatment of Seasonal Affective Disorder with Duloxetine: An Open-Label Study". Pharmacopsychiatry. 41 (3): 100–105. doi:10.1055/s-2008-1058103. ISSN 0176-3679.
  42. Lundt, L (2004). "Modafinil treatment in patients with seasonal affective disorder/winter depression: an open-label pilot study". Journal of Affective Disorders. 81 (2): 173–178. doi:10.1016/S0165-0327(03)00162-9. ISSN 0165-0327.
  43. Rohan, Kelly J.; Roecklein, Kathryn A.; Tierney Lindsey, Kathryn; Johnson, Leigh G.; Lippy, Robert D.; Lacy, Timothy J.; Barton, Franca B. (2007). "A randomized controlled trial of cognitive-behavioral therapy, light therapy, and their combination for seasonal affective disorder". Journal of Consulting and Clinical Psychology. 75 (3): 489–500. doi:10.1037/0022-006X.75.3.489. ISSN 1939-2117.
  44. Forneris, Catherine A; Nussbaumer-Streit, Barbara; Morgan, Laura C; Greenblatt, Amy; Van Noord, Megan G; Gaynes, Bradley N; Wipplinger, Jörg; Lux, Linda J; Winkler, Dietmar; Gartlehner, Gerald (2019). "Psychological therapies for preventing seasonal affective disorder". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD011270.pub3. ISSN 1465-1858.

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