Seasonal Affective Disorder (SAD) Treatment & Management

Updated: Nov 15, 2016
  • Author: David R Michael, DO; Chief Editor: Randon S Welton, MD  more...
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Treatment

Approach Considerations

Available treatments for SAD include light therapy, pharmacotherapy and psychotherapy, used either alone or in combination. No one treatment has been proven to be more efficacious than the others and are often used in combination. Therefore, it is reasonable to guide therapy based on patient preference [24] and prior response. According to the American Psychiatric Association, SAD (Major Depressive Disorder, with seasonal pattern) can be treated with the entire range of treatments available to treat Major Depressive Disorder. [17]  Of note, if bipolar disorder is evident, winter depression should not be the only target of treatment. The full spectrum of the disorder should be treated, including mania or hypomania that may be evident during the spring and summer months.

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Bright-Light Therapy

Bright-light therapy (BLT) has an established role in the treatment of seasonal affective disorder and is often referred to as the treatment of choice. [3]  The American Psychiatric Association (APA) recommends that for milder forms of seasonal affective disorder, bright-light therapy can be recommended as a 1–2 week time-limited trial as primary treatment. [17]  For more severe forms of SAD, the APA views BLT as an adjunctive treatment. While there is no data to suggest that BLT is associated with retinal or ocular damage, ophthalmologic examinations prior to initiating BLT and at regular follow-up visits for patients with pre-existing retinal disease, those taking photosensitizing medications, and those with systemic disease that involve the retina are recommended. [14] Patients often respond to BLT in as little as 1–2 weeks. Typically, BLT is continued until the time of their usual spring remission. [18]

BLT for SAD is used at an intensity of 10,000 lux for 30–90 minutes daily, usually within 1 hour of arising in the morning. Like any effective antidepressant, BLT has the potential to precipitate a hypomanic or manic episode in susceptible individuals. Other common adverse effects include eye irritation, restlessness, and transient headaches. These lamps are not a significant source of ultraviolet (UV) light.

In addition to its established role in seasonal affective disorder, BLT may be effective in nonseasonal depression or as an augmenting agent with antidepressant medication. One study found that the combination of 30 minutes of BLT a day plus 20 mg of fluoxetine significantly improves nonseasonal major depressive disorder. Data also show that light therapy alone is more effective than antidepressant monotherapy. [19]

Studies have demonstrated benefit of BLT for treatment of nonseasonal depression in pregnant patients and elderly patients. [20, 21]

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Psychotherapy

Psychotherapy, particularly cognitive-behavioral therapy (CBT) may play a role in the treatment of SAD. Though data are limited, a recent study did find that CBT was as effective as bright-light therapy for the acute treatment of SAD. [22]  Psychotherapy may be useful as an adjunct or monotherapy for the treatment of SAD. One small study did find that those participants who did CBT had a lower recurrence rate of depression the next winter than those who did bright-light therapy alone. [23]

 

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Consultations

While there is no data to suggest that bright-light therapy (BLT) is associated with retinal or ocular damage, ophthalmologic examinations are recommended prior to initiating treatment and at regular follow-up visits for patients with pre-existing retinal disease, those taking photosensitizing medications, and those with systemic disease that involve the retina. [14]

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Prevention

Preventative treatment for seasonal affective disorder (SAD) is important considering the recurrent nature of the disorder. Unfortunately, current data is limited with regards to the effectiveness of preventative measures. 

The best data for prevention of SAD episodes comes from the clinical trials that resulted in the FDA approval of bupropion XL for the prevention of SAD. [15] In this case, bupropion XL is usually initiated in the autumn prior to the onset of depressive symptoms and is continued until the spring. Data on the use of other antidepressants for the prevention of SAD is lacking. [15]

With regard to psychotherapy, one small study did find that those participants who did CBT had a lower recurrence rate of depression the next winter than those who did bright-light therapy (BLT) alone. 

There is some data showing that initiating BLT prior to the onset of a depressive episode can reduce recurrence. [24] However, a recent Cochrane review found only low-quality evidence for using BLT for the prevention of SAD and suggested that its use for this purpose be guided on patient preference. [25]

Once again, it should be noted that according to the American Psychiatric Association, SAD (Major Depressive Disorder, with seasonal pattern) can be treated with the entire range of treatments available to treat Major Depressive Disorder. [17]

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