Seasonal Affective Disorder

What is Seasonal Affective Disorder?

Seasonal affective disorder (SAD) is a type of mood disorder that comes and goes with different seasons, causing repeated periods of depression.[1] Most commonly, it usually starts in late fall or early winter and ends during spring or summer. The idea of SAD was first introduced by Rosenthal and his team in 1984, and the syndrome includes unusual features like oversleeping, overeating, craving carbohydrates, and feeling very tired, along with usual signs of depression.[2] Even though SAD happens at certain times of the year, it is not considered a separate category in the official manual for mental disorders (DSM-5-TR). Instead, it is treated as a variant of major depressive disorder and bipolar disorder.[3] The categorization of SAD in DSM-5 TR is a topic of ongoing debate which points out the necessity for more rigorous research.[4]

It is important to understand the symptoms and causes of SAD to develop effective treatments, as it can significantly impact mental health of affected individuals.[1] Research has found that how common SAD is can change depending on location, with it being more common in countries that are further from the equator. This shows that exposure to daylight may play a part in causing the disorder. The number of people affected by SAD can vary between 1% to 10% depending on where you live and how it is diagnosed, with different rates in countries like the US and Australia.[5][6][7][8] The causes of SAD are complex and likely to involve disruptions in your body clock, changes in levels of melatonin and serotonin (chemicals in your brain), and how sensitive you are to light.[9] These elements emphasise the need to research more about the biological and neurological causes of SAD.[10][11]

What Causes Seasonal Affective Disorder?

Seasonal Affective Disorder (SAD) is thought to be caused by several factors. Many experts believe that lack of sunlight and changes in hormones can significantly contribute to this condition. SAD typically starts in the fall and continues through the winter, a time when daylight hours are shorter.

SAD is linked to chemicals in the brain known as neurotransmitters, specifically dopamine, norepinephrine, and glutamate, although the exact way these affect SAD is not entirely known. The body’s internal biological clock that controls sleep and wake cycles, or circadian rhythm, can be disrupted due to decreased exposure to sunlight during the fall and winter. This disruption is believed to be a factor in the development of winter-onset SAD.

Besides, changes in levels of the hormone melatonin during different seasons can affect sleep patterns and mood. This is because melatonin helps regulate sleep and plays a role in mood stabilization.

Risk Factors and Frequency for Seasonal Affective Disorder

Seasonal Affective Disorder (SAD) is a prevalent condition affecting many people. The number of people it affects varies depending on where you live and your personal risk factors. Areas far from the equator where daylight hours change drastically between seasons have more instances of SAD. Women are more prone to SAD than men, and symptoms usually start in early adulthood.

• The prevalence of SAD tends to be higher in young adults who have peak hormone production and are more sensitive to slight environmental changes, such as sunlight variations, compared to older adults.
• Winter depression, a form of SAD, is more common than summer depression, with prevalence rates of 3% and 0.1% respectively.
• SAD is more likely in people with a family history of depression or personal history of bipolar disorder.
• In the US, the prevalence of SAD differs from state to state, ranging from 9.7% in New Hampshire to 1.4% in Florida.
• While the rate of SAD tends to increase with higher latitudes in North America, this trend isn’t statistically significant in other parts of the world.
• However, the current global and United States data on SAD prevalence is outdated by about 20 years and requires further study.

Signs and Symptoms of Seasonal Affective Disorder

Seasonal Affective Disorder, or SAD, is a form of depression that follows a seasonal pattern. Diagnosing and managing this condition requires a thorough understanding of the patient’s medical history, considering that SAD can also be a variant of major depressive or bipolar disorders. Further, other psychiatric conditions like alcohol use disorders, anxiety disorders, and personality disorders often coexist with SAD, making diagnosis and treatment more complex.

Compiling a comprehensive patient’s history for SAD would need to focus on the following key areas:

• The chronology and seasonality of symptoms: This requires a detailed account of when symptoms begin, how long they last, and when they remit. The goal is to differentiate SAD from other disorders that can also show seasonal variations.
• Specific symptoms: SAD is typically manifested through symptoms such as oversleeping, excessive eating, weight gain, and carbohydrate craving during winter months. Less commonly, depression in summer months may display insomnia, decreased appetite, and weight loss.
• The impact of these symptoms on the patient’s daily activities: This helps to understand how SAD affects the patient’s work, relationships, and overall quality of life.
• A record of past episodes and treatments: Any past disturbances in mood, treatments received, and their outcomes can provide valuable insights for developing a personalized treatment strategy.
• Family history: Given that propensity for SAD or other forms of depression is often genetic, any family history of mood disorders should be noted.
• Medical history: A comprehensive review of medical history, including any eye conditions, is critical because some conditions may be a contraindication for bright light therapy – a common treatment for SAD.
• Substance use: Documenting use of alcohol, drugs, or medication is crucial as these could affect mood and complicate the diagnosis of SAD.
• Suicidality: SAD can increase the risk of suicidal thoughts or actions, particularly during peak depressive episodes. Hence, any suicidal ideation or behavior must be assessed.
• Lifestyle and coping mechanisms: Details about physical activity, diet, exposure to natural light, as well as stress and depression coping strategies can offer hints toward potential adjunctive treatment options.
• Psychosocial factors: Seasonal stressors could act as triggers for depressive episodes and may not necessarily classify as SAD. Therefore, significant changes in routine or work status during the winter should be explored.

Patients with SAD often exhibit changes in behavior, speech, mood, thought process, perception, cognitive function, insight, and judgment – all of which should be evaluated in an in-depth mental status examination. They may also have an increased risk of suicide, which must be assessed. The course of SAD varies among patients, with symptoms typically improving on bright sunny days, and in some cases, extending into the summer.

Between 15-25% of individuals with bipolar disorder display a seasonal subtype, identified by a consistent seasonal occurrence of mood alternations over the last 2 years. Depression episodes emerging in autumn or winter are most common in this pattern. Obesity and higher rates of suicidality are more prevalent among these patients.

Testing for Seasonal Affective Disorder

Two common tools used to identify Seasonal Affective Disorder (SAD), a type of depression that’s related to changes in seasons, are the Seasonal Pattern Assessment Questionnaire (SPAQ) and The Seasonal Health Questionnaire. The SPAQ asks six questions related to changes in areas like sleep, social activity, mood, weight, appetite, and energy levels during different seasons. Answers are given a score from 0 (no change) to 4 (major change). Some critics argue that this questionnaire might include too many people. The Seasonal Health Questionnaire is seen as more precise and reliable for diagnosing SAD.

Diagnosing SAD involves a detailed look at the patient’s medical history and mental health status, using guidelines from the American Psychiatric Association. According to their guidebook, the DSM-5-TR which was published in 2022, SAD can be classified as a variation of major depressive disorder (MDD) or bipolar disorder, characterized by a “with seasonal pattern” label.

To receive a diagnosis of MDD with a seasonal pattern, a patient must meet the criteria of MDD and show the characteristics defined by the “with seasonal pattern” label. If it’s bipolar disorder with a seasonal pattern, the patient must first meet the criteria for bipolar disorder, and then show that they have at least one mood episode that changes with the seasons each year.

The DSM-5-TR states that a person with a “seasonal pattern” experiences major depressive episodes or mood changes each year at a certain time. They then greatly improve or have a significant reduction in their symptoms at another specific time of the year (for example, their depression lightens in the spring). Over the previous 2 years, these seasonal mood episodes must show a clear link to specific seasons and there should be no non-seasonal episodes occurring during this timeframe. Lastly, throughout the person’s life, episodes with a seasonal pattern must be more common than episodes without a seasonal pattern.

Treatment Options for Seasonal Affective Disorder

Managing Seasonal Affective Disorder (SAD) requires a variety of approaches to help lessen symptoms and improve overall well-being. Patients usually need a combination of treatment methods which include:

Bright Light Therapy: Bright Light Therapy (BLT) involves exposure to bright light for a specified duration at specific times, mostly in the early morning. An intensity of 10,000 lux for 30 minutes daily is generally recommended with the light source placed at a distance of 60 to 80 cm, as per device instructions. Alternative light intensity schedules may also be effective but might require longer exposure times. It typically takes about 2 to 3 weeks to observe improvement, continuing until symptoms naturally alleviate with the arrival of spring or summer months. Blue-enriched light sources are considered on par with standard light therapy. As for side effects, they’re usually mild and temporary, such as headaches and eye strain. Nonetheless, those with preexisting eye issues or heightened risk are encouraged to seek a thorough eye examination before commencing BLT therapy. Do note that light therapy might not be totally effective in preventing seasonal depression. Also, the benefits of BLT in treating a condition called seasonal mania is yet to be proven by solid evidence.

Psychotherapy: Therapy, especially cognitive behavioral therapy (CBT), plays a crucial role in managing SAD symptoms. It guides patients in overcoming harmful thought patterns and actions contributing to depression. A type of CBT specifically designed for individuals with SAD (known as CBT-SAD) concentrates on confronting negative seasonal-related thoughts and applying techniques to activate positive behavior. Research suggests that this approach might be as effective as light therapy and can produce lasting effects.

Antidepressant medication: Medicines that increase serotonin levels called Selective Serotonin Reuptake Inhibitors (SSRIs) are suitable for treating SAD. These may be used independently or together with light therapy. Also, a medication named bupropion has the unique recognition of being explicitly approved for preventing SAD. Studies suggest that starting bupropion treatment from September to November—before the typical onset of depressive symptoms—can help reduce instances of major depressive episodes in the winter months.

Vitamin D supplementation: A lot of individuals with SAD, particularly those suffering from the winter-pattern of the condition, have low vitamin D levels. Therefore, complementing other treatments with vitamin D supplementation may be beneficial despite research being inconclusive about vitamin D’s effectiveness as a stand-alone treatment for SAD. It’s especially recommended for people living in regions with limited sunlight exposure during colder months.

What else can Seasonal Affective Disorder be?

When diagnosing Seasonal Affective Disorder (SAD), it’s important for doctors to consider other conditions that have similar symptoms. These could include:

• Major depressive disorder (MDD): This shares many symptoms with SAD, such as prolonged sadness, loss of interest in activities, altered eating habits, sleep problems, fatigue, feeling worthless or guilty, trouble concentrating, and thinking about suicide.
• Bipolar disorder: Some people with bipolar disorder experience mood changes with the seasons, similar to SAD. However, bipolar disorder has distinct periods of manic or hypomanic episodes alternating with low mood episodes, which are not usually seen in SAD.
• Adjustment disorder with a depressed mood: Seasonal changes, such as changes in weather or holiday events, can trigger symptoms similar to SAD. However, with this disorder, the symptoms begin and end with certain stressors and often improve once the stressor is gone or the person adapts to it.
• Persistent depressive disorder (dysthymia): Similar to MDD, this disorder involves ongoing symptoms of depression, though they are usually less serious and don’t usually show a clear pattern of changing with the seasons.
• Generalized anxiety disorder (GAD): While warm people with GAD deal mostly with feelings of excessive worry, they may also show signs of depression, such as trouble sleeping, fatigue, and difficulty focusing.
• Substance use disorders: Using substances like alcohol or sedative-hypnotic medications may result in symptoms similar to depression, such as mood shifts, sleep problems, and decreased energy. This should be considered, especially if there’s a history of substance use or dependence.
• Medical conditions: Problems like hypothyroidism, vitamin deficiencies, or ongoing illnesses could cause depression-like symptoms that change with the seasons.
• Other psychiatric disorders: Conditions such as eating disorders, psychotic disorders, and personality disorders may present with symptoms of depression. It’s crucial to identify and differentiate these conditions from SAD.

For an accurate diagnosis of SAD, the patient’s history, symptoms, how their symptoms change with the seasons, and how they respond to environmental changes must all be thoroughly evaluated. Input from various mental health professionals is important to make sure the assessment is complete and the right treatment is chosen.

What to expect with Seasonal Affective Disorder

The future outcome for Seasonal Affective Disorder (SAD) varies from person to person. It can depend on a few things like the severity of your symptoms, how effective the treatment is, and your personal circumstances. However, with the right kind of help, people with SAD generally have a good chance of making improvements.

Here are a few key considerations:

* Treatment response: Many people with SAD see a significant improvement in their symptoms with treatment. This often includes light therapy, talking therapy, and medication. Most patients respond well to this kind of treatment, which helps to reduce their depressive symptoms and improve their overall well-being.

Seasonal change: Symptoms of SAD usually ease off with the arrival of spring or summer when there’s more daylight. If you’ve got winter-pattern SAD, you can look forward to your symptoms getting better as the seasons change. However, it’s important to note that if you don’t manage your condition consistently, symptoms may come back when autumn or winter rolls around again.

Relapse prevention: If you’ve had SAD before, you are more likely to get it again in future years. You can take proactive steps like sticking to your treatment even when you’re feeling better, making changes to your lifestyle, and looking after yourself particularly during high-risk seasons. These measures can help you avoid a relapse and stay well in the long term.

Other conditions: If you have other mental health or physical health conditions alongside SAD, it may affect how well you recover from SAD. If you have mood disorders, anxiety, or long-term physical illnesses, you might need a more in-depth treatment plan and more monitoring to meet your more complex needs.

Individual factors: Your own circumstances can also influence how well you do. If you can handle stress well, have solid support in your corner, stick to your treatment plan, and have the resources you need, you’re more likely to fare better. Those who take an active part in their treatment, make important lifestyle changes, and seek help from medical professionals and their friends and family are likely to see better results.

Possible Complications When Diagnosed with Seasonal Affective Disorder

Seasonal Affective Disorder (SAD), if not properly managed, can lead to several complications. These complications can affect various aspects of a person’s life, from their daily routine and relationships, to their physical health and mental well-being.

Potential complications of untreated or poorly managed SAD include:

• Impaired Functioning: SAD can significantly influence a person’s daily life. Symptoms such as persistent sadness, fatigue, and lethargy might affect their work or school performance, interpersonal connections, and overall quality of life.
• Social Isolation: People with SAD may avoid social activities and relationships due to their low mood and lack of interest. This can increase feelings of loneliness, making their depressive symptoms worse, and could potentially lead to other mental health issues.
• Substance Abuse: Some people might turn to alcohol or drugs to manage their SAD symptoms. Unfortunately, this can worsen their mood disturbances, impair their judgment, and potentially lead to addiction or substance abuse disorders.
• Suicidal Thoughts: In severe cases, untreated SAD can result in suicidal thoughts or behaviors. Proper intervention and support is crucial to prevent this from happening.
• Relationship Issues: The symptoms of SAD can strain relationships with family, friends, and partners. The disease symptoms, such as irritability, mood swings, and social withdrawal, can lead to communication issues and conflicts.
• Work or School Problems: Decreased energy, difficulties concentrating, and consistent absences due to SAD can negatively impact someone’s work or school performance. This could potentially put their job or academic success at risk.
• Physical Health Issues: SAD can cause changes in appetite, sleep disturbances, and decreased physical activity. This can increase the risk of obesity, cardiovascular diseases, and other long-term physical health problems.
• Aggravated Mental Health Conditions: If left untreated, SAD can make individuals more likely to experience recurring depressive episodes or develop other mood disorders, such as major depressive disorder or bipolar disorder.

Preventing Seasonal Affective Disorder

If you’re trying to prevent or manage seasonal affective disorder (SAD), a type of depression that’s related to changes in seasons, there are both lifestyle changes and specific steps you can take. To start with, you could try to get more natural sunlight, eat healthily, do regular exercise, and make sure you’re getting enough sleep. All of these can help to reduce your symptoms. Simple things like going for a daily walk in the daylight and making your living spaces as light and sunny as possible can also be a big benefit. Taking these proactive steps and being aware of your condition can help to stop it from becoming severe and can improve your overall wellbeing.

Knowing about the symptoms and patterns of SAD can help you to notice early signs and get treatment. You could also consider using light therapy during the autumn and winter months before your symptoms even start, which could help to prevent the disorder from taking hold. Cognitive Behavioural Therapy (CBT), a type of talk therapy, can also be preventative by giving you strategies to cope with changes in your mood throughout the year. By focusing on these proactive steps and building resilience, you can reduce the impact of SAD on your life and improve your overall mental health.