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__NOTOC__
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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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{{SI}}
{{SI}}


{{CMG}}; {{AE}} {{HW}}
{{CMG}}; {{AE}} {{Sharma}} ; {{HW}}


{{SK}} SAD; seasonal disorder; seasonal depression; winter blues; winter depression
{{SK}} SAD, seasonal disorder, seasonal depression, winter blues, winter depression


==Overview==
==Overview==
Seasonal affective disorder (SAD), also known as '''winter depression''', is a form of [[depression]] that is correlated with 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 no such instances in the late spring and summer months. Less commonly, patients may experience depressive episodes in the summer; this type of disorder 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==
==Historical Perspective==
*The seasonal variation in mood has been observed since ancient times.
 
*Hippocrates circa (400 BC) first explained regarding the 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 seasonal variation in mood is observed since ancient times.
*The Greco-Roman physicians managed depression by focussing the sunlight towards 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>
*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>
*In 1894, Cook described a disorder characterized by depressed mood, low energy, fatigue, and loss of libido, which was correlated by him 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>
*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>
*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 1980s, SAD was systematically described for the first time and named by South African physician Normal Rosenthal. He had 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 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>
*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'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==
==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 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>
*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>
* According to the Diagnostic and Statistical Manual of Mental Disorders(DSM), SAD does not exist as a separate disorder.  
*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>
*In DSM-5, seasonal variation in mood is mentioned as a specifier for both Major Depression disorder (Recurrent episodes) and Bipolar Disorder (both Bipolar I and 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>
*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]].
*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 symptomalology 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>
*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==
*The pathophysiologic basis of SAD is not completely understood.
*The pathophysiologic basis of SAD is not completely understood.
*There is a combined effect of circadian, neurotransmitter, and genetic modulations.  
*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 [[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 suffer from some of the following hormonal/[[neurotransmitter]] imbalances:<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 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 winter months than in the summers, causing the overall lesser effect of serotonin in winters.
 
#'''[[Norepinephrine]]''' levels are also found to be low in these patients.
#'''[[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>
#'''[[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]].
#'''[[Norepinephrine]]:''' [[Catecholamine]] levels are also found to be low in these patients.
#'''[[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.
#'''[[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>


==Causes==
==Differential Diagnosis==
The cause of SAD has not yet been determined, though both genetic and environmental factors appear to play a role.<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>
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>


==Differentiating seasonal affective disorder from other diseases==
SAD must be differentiated from diseases that present with similar symptoms, including:<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="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]]
*[[Major depressive disorder]]
*[[Atypical depression]]
*[[Bipolar Disorder]]
*[[Hypothyroidism]]
*[[Hypothyroidism]]
*Seasonal occupational stressors
*Seasonal [[psychosocial]] stressors


==Epidemiology and Demographics==
==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>
 
*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===
===Age===
SAD is most commonly diagnosed in young 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>
 
*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===
===Gender===
SAD is more common in women than in 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>
 
*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===
===Race===
No racial predilection for SAD has been observed.
 
*SAD has no specific racial predilection.


==Risk Factors==
==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>
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>
*Being female
 
*Living far from the equator
*Female gender
**SAD is particularly prevalent 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>
*Age less than 40 years
*Having a family history of any type of [[depression]]
*Higher latitude
*Being a young adult
*Family history of [[depression]]
*5-HTTLPR [[gene]] [[polymorphism]]
*Sociocultural factors (for adolescents)


==Screening==
==Screening==
No formal screening guidelines exist for SAD. The Seasonal Pattern Assessment Questionnaire (SPAQ), developed by Rosenthal in 1984, is an effective, self-administered tool for patients who think they might be suffering from 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>
 
*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==
==Natural History, Complications, and Prognosis==
*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>
 
*SAD can be a serious disorder and may necessitate hospitalization.<ref name = "Modell"/>
*SAD can be a very serious disorder and may require hospitalization.<ref name="Modell" />
**There is also potential risk of [[suicide]] in some patients experiencing SAD.
*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>
**One study reports 6-35% of sufferers required hospitalization during one period of illness.
*The symptoms mimic those of [[clinical depression]], with seasonal variability.
**The symptoms of SAD mimic those of [[dysthymia]] or [[clinical depression]].
*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>
*With treatment, the prognosis of SAD is generally good, though some people with SAD continue to experience the full effects of the disorder throughout their lives.<ref name=”MedLine”> U.S. National Library of Medicine. MedlinePlus. “Seasonal affective disorder.” 2016. https://medlineplus.gov/ency/article/001532.htm </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==
==Diagnosis==


===Diagnostic Criteria===
===Diagnostic Criteria===
A diagnosis of SAD is appropriate for patients who meet all of the criteria for a diagnosis of [[major depression]] and in whom the incidence of depression has been observed to correspond to the onset of specific seasons for a period of no less than 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>
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===
===Symptoms===
General symptoms of [[major depression]] 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>
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 a majority of the time
 
*Feeling hopeless or insignificant
*Feeling [[depressed]]
*Feeling hopeless
*[[Lethargy]]
*[[Lethargy]]
*Losing interest in activities one previously enjoyed
*Lack of interest in activities enjoyed earlier
*[[Insomnia|Having trouble sleeping]]
*[[Insomnia|Having trouble sleeping]]
*Experiences changes in appetite or weight
*Changes in [[appetite]] or weight
*Having difficulty concentrating
*Difficulty concentrating
*Having frequent thoughts of death or [[suicide]]
*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>


Symptoms of winter-occurring 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>
*[[Lethargy]]
*[[Lethargy]]
*[[Hypersomnia]]
*[[Hypersomnia]]
*[[Overeating]] and weight gain
*[[Overeating]] and [[weight gain]]
*Craving carbohydrates and sugars
*Craving [[Carbohydrate|carbohydrates]] and [[Sugar|sugars]]
*Social withdrawal
*Social withdrawal


Symptoms of summer-occurring 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>
[[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>
*Decreased appetite and weight loss
 
*The decreased [[appetite]] and [[weight loss]]
*[[Insomnia]]
*[[Insomnia]]
*[[Agitation]] and restlessness
*[[Agitation]] and restlessness
Line 120: Line 159:
*Episodes of violence
*Episodes of violence


===Physical Examination===
===Diagnostic and Statistical Manual of Mental Disorders (DSM)===
There is no formal, established test for SAD. A diagnosis is made by asking a patient about his/her history of symptoms.<ref name=”MedLine”> U.S. National Library of Medicine. MedlinePlus. “Seasonal affective disorder.” 2016. https://medlineplus.gov/ency/article/001532.htm </ref>


===Laboratory Findings===
*[[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>
Though no laboratory findings are diagnostic of SAD, a healthcare professional may need to perform [[blood tests]] to rule out other disorders that present with similar symptomology.<ref name=”MedLine”> U.S. National Library of Medicine. MedlinePlus. “Seasonal affective disorder.” 2016. https://medlineplus.gov/ency/article/001532.htm </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.


===Imaging Findings===
===International Classification of Diseases, Tenth Edition (ICD-10)===
No imaging findings are associated with SAD.


===Other Diagnostic Studies===
*ICD-10 does not include specific clinical guidelines for diagnosing SAD.
No other diagnostic modalities are associated with 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.


==Treatment==
==Treatment==


===Medical Therapy===
*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>
*Options for the treatment of SAD include medication, [[light therapy]], [[psychotherapy]], and the administration of [[vitamin D]].
*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>
*Any of these therapies may be used on its own or in combination with another.<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>
 
====Light Therapy====
 
*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>
*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>


====Medication====
====Medications====
*SAD may be treated with [[selective serotonin reuptake inhibitors]] (SSRIs). [[Bupropion]], a type of SSRI, has been specifically approved by the FDA for the treatment of SAD.<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>
*Common side effects of bupropion include [[drowsiness]], [[anxiety]], [[dry mouth]], [[dizziness]], [[weight loss]], and [[sore throat]].<ref>U.S. National Library of Medicine. MedlinePlus. “Bupropion.” 2016. https://medlineplus.gov/druginfo/meds/a695033.html </ref>
*Common side effects of SSRIs include [[nausea]], [[diarrhea]], [[constipation]], [[vomiting]], [[dry mouth]], weight changes, and [[headaches]].<ref>U.S. National Library of Medicine. MedlinePlus. “Sertraline.” 2016. https://medlineplus.gov/druginfo/meds/a697048.html </ref>


====Light Therapy====
*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>
*SAD has been treated primarily with [[light therapy]], also referred to as bright light therapy (BLT) or [[phototherapy]], since the 1980s.<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>
*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>
**The rationale behind the use of [[light therapy]] is that the [[depressive]] effect of decreased sunlight during the late fall and winter months can be counteracted through daily exposure to bright light.  
*[[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>
**Patients who undergo [[light therapy]] typically use a light box each morning from early fall until the start of spring.
*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>
**The use of light boxes generally calls for between 20 and 60 minutes of exposure to 10,000 lux of cool-white fluorescent light, which is approximately 20 times greater in brightness than standard lighting.
*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>
*As evidence of the efficacy of light therapy as compared to other treatment options is far from conclusive, experts recommend that decisions about forms of treatment be guided greatly by the preferences of individual patients.<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>
*[[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>
*Common side effects of light therapy include [[eye strain]] and [[headaches]].<ref name=”MedLine”> U.S. National Library of Medicine. MedlinePlus. “Seasonal affective disorder.” 2016. https://medlineplus.gov/ency/article/001532.htm </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>
*Light therapy is contraindicated for individuals 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>


====Psychotherapy====
====Psychotherapy====
*The use of [[psychotherapy]], specifically [[cognitive behavioral therapy]] (CBT), to treat SAD is common.<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>
**CBT helps patients recognize and replace depressing thoughts.
**Patients are also encouraged to engage in activities they find pleasing and engaging as a technique for coping with their symptoms.


====Vitamin D====
*The use of [[psychotherapy]], specifically [[cognitive behavioral therapy]] ([[Cognitive-behavioral therapy|CBT]]), to treat SAD is common.
*Though the administration of [[vitamin D]] has not been proven to be an effective treatment for SAD, researchers have postulated that it may be helpful due to decreased vitamin D levels observed in SAD patients.<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>
*[[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>
**Studies intended to determine the efficacy of vitamin D as a treatment for SAD have yielded mixed results.
*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>


===Surgery===
* 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.
Surgery is not recommended for the management of SAD.
 
===Prevention===
*There are no established measures for the primary prevention of SAD.
*Measures for the secondary prevention of SAD include:<ref name=”MedLine”> U.S. National Library of Medicine. MedlinePlus. “Seasonal affective disorder.” 2016. https://medlineplus.gov/ency/article/001532.htm </ref>
**Getting an adequate amount of sleep
**Eating a healthy, balanced diet
**Taking medicine as directed
**Exercising regularly
**Avoiding [[alcohol]] and illegal drugs


==References==
==References==
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[[Category:Psychiatry]]
[[Category:Psychiatry]]
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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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