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Seasonal Affective Disorder

Original Editor - Kapil Narale

Top Contributors - Kapil Narale  

Introduction

Seasonal Affective Disorder (SAD) is a common condition which is experienced by millions of people. Many people who experience such a disorder may be unaware of having the condition. It usually begins in young adulthood. [1] SAD is a condition which entails an extreme change in mood and behaviour associated with particular seasons. [2] [3][4] It is a recurring phenomenon, generally in the seasons of Fall and Winter, which can also show effects in Spring or Summer. [5] It can be noted as a severe mental health concern and a public health challenge, since it is very prevalent with recurrences, prolonged durations, and varied impairments. [6]

A less severe form of SAD is known as subsyndromal SAD (S-SAD). [7]

Individuals with SAD can have depressive symptoms which may span up to 40% of the year, which can have a socio-professional and/or economic impact. [8] It is also seen to be associated with an increased severity of bipolar disorder [9] and cardiovascular risk factors. [10]

A ssimilar condition known as summer-pattern SAD or summer depression can also occur in the Spring and Summer months, which is less common. [1]

Diagnosis

It can be categorised using the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). The diagnosis of Seasonal Pattern (SP) includes two consecutive occurrences of a major depressive or manic episode at a particular time of the year, [11] in two separate consecutive years. [1] This would be followed by a full remission or alteration from major depression to mania or hypomania, or vice versa. [11]

It is seen that SAD is a rare condition and is not easily identified by the Seasonal Pattern Assessment Questionnaire (SPAQ). However, the SPAQ is an objective measure used to diagnose SAD. [12] More information can be found on the page Seasonal Pattern Assessment Questionnaire.

Here is a copy of the SPAQ that can be used as an assessment.

Epidemiology

SAD can be seen to inherited genetically, within families, and may be more common in people with relatives experiencing other mental illnesses such as depression or schizophrenia. [1]

There is a lower prevalence of SAD seen with increasing age, [13] as it progresses more slowly. [14] There is a higher prevalence seen in Women, [1][13] occurring 1.5x more than in Men. [14] Nonseasonal depression is seen to have a prevalence which becomes stable after the age of 30. [15] It is seen that the occurrence of SAD is overestimated in individuals with bipolar disorder. It is estimated that a 25% of patients present a seasonal pattern with their depressive episodes. [16][17] It occurs at a prevalence of 1-10% at high altitude. [18]

The prevalence rate shows that SAD affects about 4% of the population, while 13.5% experience S-SAD. [19]

Etiology

SAD can stem from a variety of factors. There can be genetic variants in the circadian clock genes, [9][20][21][22] a phase shift in circadian rhythm [23], irregular release of melatonin, [23][24] and changes within the serotoninergic system. [25][26]

It is possible that there can be a reduced level of the mood regulating chemical, serotonin. Sunlight affects levels of molecules that help maintain serotonin levels. Less daylight hours may limit these molecules from producing sufficient serotonin levels, leading to inadequate levels in the Winter. [1]

Symptoms

Symptoms generally persist for 4-5 months. [1]

Not all symptoms outlined may be present. Possible symptoms include: [1]

  • Depression[18]
  • Continuous sad, anxious, or “empty” mood much of the day, almost every day, for at least 2 weeks
  • Feelings of hopelessness or pessimism
  • Feelings of irritability, frustration, or restlessness
  • Feelings of guilt, worthlessness, or helplessness
  • Loss of interest or pleasure in hobbies and activities
  • Reduced energy, increased fatigue (lethargy [18]), or feeling slowed down
  • Trouble concentrating, remembering, or decision making
  • Sleep or appetite disturbance, with variations in circadian rhythm
  • An unexpected weight changes
  • Aches or pains, headaches, cramps of a physical nature, or unexplained and unexpected digestive issues which do not resolve with treatment
  • Suicidal thoughts or attempts

Additional symptoms can include:

  • Oversleeping (hypersomnia) [18]
  • Overeating, especially having a craving for carbohydrates [18], thus leading to weight gain
  • Experiencing social withdrawal (feeling like “hibernating”)

SAD and Vitamin D

It is seen that SAD and poor mental wellbeing are associated with low levels of serum Vitamin D. [18] Vitamin D is said to promote the production of serotonin, therefore a deficiency in vitamin D may lead to a greater risk of SAD, due to a lower level of serotonin. Other than Vitamin D in foods, it is produced on the skin when exposed to sunlight. With less sunlight levels in the Winter, there will be less Vitamin D produced, hence less serotonin produced as well. [1]

It is a clinical syndrome with symptoms generally ranging from depression, carbohydrate craving, hypersomnia, lethargy, and variations in circadian rhythm. [18]

Symptoms generally occur at the same times of the year, namely Fall, Winter [27], and early Spring, between October and March, at latitudes higher than 37 N [18] [28] when it is noticeably darker. [27] [29] In these cases, affected individuals would want to seek sunnier and warmer locations where they can have a higher exposure to Vitamin D and Vitamin D production. In some instances, individuals may travel to southern parts of the country or continent, where there are warmer temperatures and sunnier conditions, to help mitigate depressive types of symptoms. [27]

It was found by Kerr et al, that there was a variation in depression and Vitamin D levels, within different seasons. However, this was seen in a group of 185 healthy females.[30] Similarly, it was found by Premkumar et al, that having a lower level of Vitamin D led to symptoms of depression during a 1 year stay in the Antarctic. [31] Some studies have found that Vitamin D supplementation helped with reducing depressive symptoms, [32][33] [34] however most studies did not conclude a positive association for Vitamin D supplementation and SAD or mood changes based on the season. [35] In a particular study of 250 females provided with a supplementation of 40IU of Vitamin D for 1 year, mood scores did not change with varying seasons. [36] Likewise, a study by Dumville et al did not find mood improvements in a sample of 1621 women who were randomised to 800 IU of Vitamin D for 6 months. [37] Another two RCTs, one involving 34 subjects with SAD given supplementation for 3 months [38], and another involving 243 subjects with low levels of Vitamin D given supplementation for 6 months, [39] found that there was no reduction in symptoms. [38] [39] It is seen that there are limitations to these studies based on sample sizes, gender, age, supplementation schedule, assessment scales, and other factors, and more research is needed to reach conclusions on the effect of Vitamin D on SAD.

SAD and Melatonin

Melatonin is important for maintaining the sleep-wake cycle. Varied levels of this hormone can be related to SAD. It should be noted that individuals with SAD produce excess levels of melatonin, thus may experience inrceased sleepiness and lead to oversleeping. [1]

Co-morbidities with Other Disorders

SAD can affect individuals with unipolar or bipolar disorders, and usually occur in relation to Seasonal Patterns of recurring depressive episodes. [11] It can be recognised as a multidisciplinary disorder, which can affect patients with unipolar or bipolar disorders. [5]

SAD is more common in people with depression or bipolar disorder. Of these disorders, it especially occurs in people with bipolar II disorder, involving repeated depressive episodes, and hypomanic episodes, which are less intense than the usual manic episodes of bipolar I disorder. [1]

People with SAD can have also other mental disorders, including attention-deficit hyperactive disorder (ADHD), eating disorder, anxiety disorder, or panic disorder. [1]

Treatment

Treatments can be used on their own, or in combination. There are four main types of treatments, which include: [1]

  • Light Therapy
  • Psychotherapy
  • Antidepressant medication
  • Vitamin D supplementation

Light therapy and Vitamin D supplementation are therapies for 'Winter-pattern' SAD. Psychotherapy and antidepressant medication are therapies generally used to treat depression. [1]

Light Therapy

This was used as a therapy since the 1980s. The use of light therapy helps to expose the individuals with SAD to a bright light as a supplement to the lower amounts of natural light in the darker months. [1]

The person sits in front of a very bright light box (10, 000 lux) for about 30-45 mins a day. This is usually done first thing in the morning everyday from Fall to Spring. The light box is 20 times brighter than usual indoor light. This is a safe treatment since any harmful UV rays are filtered out. Alternatively, people with certain eye conditions or those taking certain medications that increase sensitivity to sunlight may need to use another treatment, or make use light therapy with medical supervision. [1]

Psychotherapy

Psychotherapy can be referred to as 'talk therapy' or counselling'. This helps educate people with SAD about new methods of thinking and behaving, and altering their lifestyle or habits that are leading to depression. [1]

Cognitive Behavioural Therapy (CBT) is a type of psychotherapy that helps people adjust and modify unhelpful thoughts and behaviours, to change and improve their depressive and anxious feelings. CBT can be used with SAD and its sue is known as CBD-SAD. This is administered in two weekly group sessions for six weeks, which aims to replace negative thoughts related to the season with more positive and cheerful thoughts. CBT-SAD also uses a technique called behavioral activation. This helps people identify and make time for pleasant, engaging indoor or outdoor activities to mitigate the loss of interest that is experience in the Winter months. [1]

CBD-SAD compare to light therapy were equally effective with improving SAD symptoms, however some SAD symptoms were better resolved with light therapy. However, a long term study over two years found that CBD was a more effective treatment. [1]

Antidepressant Medication

These can be used alone, or in combination with psychotherapy. They work by modulating how the brain produces certain chemicals to regulate mood or stress. They usually take 4-8 weeks to have an effect on the body. It is seen that issues with sleep, appetite, and concentration are often resolved before changes in mood are normalised. [1]

It is important to give the medication a try before deciding if it is suitable for you, especially since they do take a long time to take effect. [1]

Since SAD is related to a variability in serotonin activity, antidepressants called selective serotonin reuptake inhibitors can be used to significantly lift up a person's mood. [1]

Bupropion has been approved for use by the U.S. in an extended release form which is designed to last longer. Bupropion helps prevent the recurring symptoms of seasonal depression when administered daily from the Fall to early Spring. [1]

It is evident that all medications may have side effects, thus should be taken with caution, and/or with medical supervision. [1]

Vitamin D

It is interesting to note that studies testing Vitamin D for the treatment of SAD have proven mixed results. [1]

See the SAD and Vitamin D section above and the Vitamin D and the Effect on Mental Health page for further information.

Be careful with Vitamin D supplementation, since it may interact with other medications. [1]

Prevention

SAD can be prevented by commencing such treatment methods before the beginning of the darker seasons, thus helping to reduce depression symptoms. [1]

Speak to your Healthcare provider for further ideas and suggestions. [1]

Videos

Here are some videos explaining Seasonal Affective Disorder:

[40]
[41]


References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 National Institute of Mental Health. Seasonal Affective Disorder. Available from: https://www.nimh.nih.gov/health/publications/seasonal-affective-disorder (accessed 11/11/2024).
  2. ↑ Bauer M, Dunner D. Validity of Seasonal Pattern as a Modifier for Recurrent Mood Disorders for DSM-IV. Comprehensive Psychiatry. 1993:34(3):159-170.
  3. ↑ Geoffroy P.A, Bellivier F, Scott J, Etain B. Seasonality and Bipolar Disorder: A Systematic Review, from Admission Rates to Seasonality of Symptoms. Journal of Affective Disorders. 2014:168:210–223.
  4. ↑ Murray G. The Seasonal Pattern Assessment Questionnaire as a Measure of Mood Seasonality: A Prospective Validation Study. Psychiatry Resources. 2003:120:53–59.
  5. ↑ 5.0 5.1 Rosenthal N.E, Sack D.A, Gillin J.C, Lewy A.J, Goodwin F.K, Davenport Y, Mueller P.S, Newsome D.A, Wehr T.A. Seasonal Affective Disorder. A Description of the Syndrome and Preliminary Findings with Light Therapy. Archives in General Psychiatry. 1984:41:72–80.
  6. ↑ Rohan K.J, Roecklein K.A, Haaga D.A.F. Biological and Psychological Mechanisms of Seasonal Affective Disorder: A Review and Integration. Current Psychiatry Reviews. 2009:5:37–47.
  7. ↑ Kasper S, Rogers S.L, Yancey A, Schulz P.M, Skwerer R.G, Rosenthal N.E. Phototherapy in individuals with and without subsyndromal seasonal affective disorder. Archives in General Psychiatry. 1989:46:837-844.
  8. ↑ Kurlansik S.L, Ibay A.D. Seasonal Affective Disorder. American Family Physician. 2012:86:1037–1041.
  9. ↑ 9.0 9.1 Geoffroy P.A, Lajnef M, Bellivier F, Jamain S, Gard S, Kahn J.P, Henry C, Leboyer M, Etain B. Genetic Association Study of Circadian Genes with Seasonal Pattern in Bipolar Disorders. Scientific Reports. 2015:5:10232.
  10. ↑ Geoffroy P.A, Godin O, Mahee D, Henry C, Aubin V, Azorin J.M, Bougerol T, Courtet P, Gard S, Kahn J.P, Passerieux C, Leboyer M, Bellivier F, Etain B, FACE-BD coll. Seasonal Pattern in Bipolar Disorders and Cardio-Vascular Risk Factors: A Study from the FACE-BD Cohort. Chronobiology International. 2017: 34:845–854.
  11. ↑ 11.0 11.1 11.2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association: Arlington, VA, USA, 2013.
  12. ↑ Magnusson A. Validation of the Seasonal Pattern Assessment Questionnaire (SPAQ). Journal of Affective Disorders. 1996:40:121–129.
  13. ↑ 13.0 13.1 Chotai J, Smedh K, Johansson C, Nilsson L.G, Adolfsson R. An Epidemiological Study on Gender Differences in Self-Reported Seasonal Changes in Mood and Behaviour in a General Population of Northern Sweden. Nordic Journal of Psychiatry. 2004: 58:429–437.
  14. ↑ 14.0 14.1 Chotai J, Smedh K, Johansson C, Nilsson L.G, Adolfsson R. An Epidemiological Study on Gender Differences in Self-Reported Seasonal Changes in Mood and Behaviour in a General Population of Northern Sweden. Nordic Journal of Psychiatry. 2004:58:429–437.
  15. ↑ Salk R.H, Hyde J.S, Abramson L.Y. Gender Differences in Depression in Representative National Samples: Meta-Analyses of Diagnoses and Symptoms. Psychological Bulletin. 2017:143:783–822.
  16. ↑ Geoffroy P.A, Bellivier F, Scott J, Etain B. Seasonality and Bipolar Disorder: A Systematic Review, from Admission Rates to Seasonality of Symptoms. Journal of Affective Disorders. 2014: 168:210–223.
  17. ↑ Geoffroy P.A, Bellivier F, Scott J, Boudebesse C, Lajnef M, Gard S, Kahn J.P, Azorin J.M, Henry C, Leboyer M, Etain B. Bipolar Disorder with Seasonal Pattern: Clinical Characteristics and Gender Influences. Chronobiological International. 2013:30: 1101–1107.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 18.5 18.6 18.7 Frandsen T.B, Pareek M, Hansen J.P, Nielsen C.T. [https://pubmed.ncbi.nlm.nih.gov/25125215/ Vitamin D supplementation for treatment of seasonal affective symptoms in healthcare professionals: a double-blind randomised placebo-controlled trial.] BMC Research Notes 2014:7(528):1-8.
  19. ↑ Kasper S, Wehr T.A, Bartko J.J, Gaist P.A, Rosenthal N.E. Epidemiological findings of seasonal changes in mood and behaviour. Archives in General Psychiatry. 1989:46:823-833.
  20. ↑ Kovanen L, Donner K, Kaunisto M, Partonen T, CRY1 and CRY2 Genetic Variants in Seasonality: A Longitudinal and Cross-Sectional Study. Psychiatry Resources. 2016:242:101–110.
  21. ↑ Zhang L, Hirano A, Hsu P.K, Jones C.R, Sakai N, Okuro M, McMahon T, Yamazaki M, Xu Y, Saigoh N, Saigoh K, Lin S-T, Kaasik K, Nishino S, Ptacek L.J. A PERIOD3 Variant Causes a Circadian Phenotype and Is Associated with a Seasonal Mood Trait. Procedures in National Academic Sciences. 2016:113:1536–1544.
  22. ↑ Kim H.I, Lee H.J, Cho C.H, Kang S.G, Yoon H.K, Park Y.M, Lee S.H, Moon J.H, Song H.M, Lee E, Kim L. Association of CLOCK, ARNTL, and NPAS2 Gene Polymorphisms and Seasonal Variations in Mood and Behavior. Chronobiology International. 2015:32:785–791.
  23. ↑ 23.0 23.1 Lewy A.J, Lefler B.J, Emens J.S, Bauer V.K. The Circadian Basis of Winter Depression. Procedures in National Academic Science. 2006:103:7414–7419.
  24. ↑ Terman M, Terman J.S, Quitkin F.M, Cooper T.B, Lo E.S, Gorman J.M, Stewart J.W, McGrath P.J. Response of the Melatonin Cycle to Phototherapy for Seasonal Affective Disorder. Journal of Neural Transmission. 1988: 72:147–165.
  25. ↑ Levitan R.D. The Chronobiology and Neurobiology of Winter Seasonal Affective Disorder. Dialogues Clin. Neurosci. 2007, 9, 315–324.
  26. ↑ Tyrer A.E, Levitan R.D, Houle S, Wilson A.A, Nobrega J.N, Meyer J.H. Increased Seasonal Variation in Serotonin Transporter Binding in Seasonal Affective Disorder. Neuropsychopharmacol. Off. Publ. Am. Coll. Neuropsychopharmacol. 2016, 41, 2447–2454.
  27. ↑ 27.0 27.1 27.2 Humble M.B. Vitamin D, light and mental health. Journal of Photochemistry and Photobiology B: Biology. 2010:101;142-149.
  28. ↑ Rucker D, Allan J.A, Fick G.H, Hanley D.A. Vitamin D insufficiency in a population of healthy western Canadians. Canadian Medical Association Journal. 2002:166(12):1517–1524.
  29. ↑ Wirz-Justice A. Seasonality in affective disorders. General Compilation of Endocrinology. 2018:258:244–249.
  30. ↑ Kerr D.C, Zava D.T, Piper W.T, Saturn S.R, Frei B, Gombart A.F. Associations between vitamin D levels and depressive symptoms in healthy young adult women. Psychiatry Resources. 2015:227(1):46–51.
  31. ↑ Premkumar M, Sable T, Dhanwal D, Dewan R. Vitamin D homeostasis, bone mineral metabolism, and seasonal affective disorder during 1 year of Antarctic residence. Archives of Osteoporosis. 2013:8:129.
  32. ↑ Lansdowne A.T, Provost S.C. Vitamin D3 enhances mood in healthy subjects during winter. Psychopharmacology. 1998:135(4):319–323.
  33. ↑ Gloth F.M, Alam W, Hollis B. Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder. Journal of Nutritional Health and Aging. 1999:3(1):5–7.
  34. ↑ Vieth R, Kimball S, Hu A, Walfish P.G. Randomized comparison of the effects of the vitamin D3 adequate intake versus 100 mcg (4000 IU) per day on biochemical responses and the wellbeing of patients. Nutritional Journal. 2004:3:8.
  35. ↑ Casseb G.A.S, Kaster M.P, Rodrigues A.L.S. Potential Role of Vitamin D for the Management of Depression and Anxiety. CNS Drugs. 2019:33:619–637.
  36. ↑ Harris S, Dawson-Hughes B. Seasonal mood changes in 250 normal women. Psychiatry Resources. 1993:49(1):77–87.
  37. ↑ Dumville J.C, Miles J.N, Porthouse J, Cockayne S, Saxon L, King C. Can vitamin D supplementation prevent winter-time blues? A randomised trial among older women. Journal of Nutritional Health & Aging. 2006:10(2):151–153.
  38. ↑ 38.0 38.1 Frandsen T.B, Pareek M, Hansen J.P, Nielsen C.T. Vitamin D supplementation for treatment of seasonal affective symptoms in healthcare professionals: a double-blind randomised placebo-controlled trial. BMC Resources Notes. 2014:7:528.
  39. ↑ 39.0 39.1 Kjaergaard M, Waterloo K, Wang C.E, Almas B, Figenschau Y, Hutchinson M.S, Svartberg J, Jorde R. Effect of vitamin D supplement on depression scores in people with low levels of serum 25-hydroxyvitamin D: nested case-control study and randomised clinical trial. British Journal of Psychiatry. 2012:201(5):360–368.
  40. ↑ Psych2Go. 6 Signs You Have Seasonal Affective Disorder (SAD). Available from: https://www.youtube.com/watch?v=HWBJpATz7-w&ab_channel=Psych2Go (accessed 05/11/2024).
  41. ↑ ABCNews. Coping with seasonal affective disorder. Available from: https://www.youtube.com/watch?v=0dcMFwSpLd0&ab_channel=ABCNews (accessed 04/11/2024).
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