Evidence-Based Reviews

SAD: Is seasonal affective disorder a bipolar variant?

Current Psychiatry. 2010 February;9(2):43-54

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

2. Lam RW, Levitt AJ. eds. Clinical guidelines for the treatment of seasonal affective disorder. Vancouver, BC: Clinical and Academic Publishing; 1999.

3. Rosenthal NE, Sack DA, Gillin JC, et al. Seasonal affective disorder. A description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry. 1984;41(1):72-80.

4. Michalak EE, Wilkinson C, Hood K, et al. Seasonal and nonseasonal depression: how do they differ? Symptom profile, clinical and family history in a general population sample. J Affect Disord. 2002;69(1-3):185-192.

5. Goodwin FK, Jamison KR. Manic-depressive illness: bipolar disorders and recurrent depression. 2nd ed. New York, NY: Oxford University Press; 2007.

6. Sohn CH, Lam RW. Treatment of seasonal affective disorder: unipolar versus bipolar differences. Curr Psychiatry Rep. 2004;6(6):478-485.

7. Goikolea JM, Colom F, Martinez-Aran A, et al. Clinical and prognostic implications of seasonal pattern in bipolar disorder: a 10-year follow-up of 302 patients. Psychol Med. 2007;37:1595-1599.

8. Kessler RC, Zhao S, Blazer DG, et al. Prevalence, correlates, and course of minor depression and major depression in the National Comorbidity Survey. J Affect Disord. 1997;45(1-2):19-30.

9. Modell JG, Rosenthal NE, Harriett AE, et al. Seasonal affective disorder and its prevention by anticipatory treatment with bupropion XL. Biol Psychiatry. 2005;58:658-667.

10. Cassidy F, Carroll BJ. Seasonal variation of mixed and pure episodes of bipolar disorder. J Affect Disord. 2002;68:25-31.

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15. Goel N, Terman M, Terman JS, et al. Summer mood in winter depressives: validation of a structured interview. Depress Anxiety. 1999;9:83-91.

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19. Williams JB, Link MJ, Rosenthal NE, et al. Structured Interview Guide for the Hamilton Depression Rating Scale - Seasonal Affective Disorder Version (SIGH-SAD). New York, NY: New York State Psychiatric Institute; 1992.

20. Wu JC, Kelsoe JR, Schachat C, et al. Rapid and sustained antidepressant response with sleep deprivation and chronotherapy in bipolar disorder. Biol Psychiatry. 2009;66(3):298-301.

21. Golden RN, Gaynes BN, Ekstrom RD, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry. 2005;162(4):656-662.

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27. Lam RW, Levitt AJ, Levitan RD, et al. The Can-SAD study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder. Am J Psychiatry. 2006;163:805-812.

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We plan to administer the Hypomania Interview Guide (including Hyperthymia) for Seasonal Affective Disorder (HIGH-SAD) during treatment and the following spring to monitor prospectively for hypomanic symptoms.

Assessment tools

After complete assessment for mood episodes and mood disorders based on DSM-IV-TR, an additional assessment for bipolarity and seasonality may be helpful.¹

Screen for bipolarity in patients with SAD to avoid triggering mania or hypomania during treatment. Useful tools include:

HIGH-SAD¹⁵
the National Institutes of Health Life Chart Method to establish a recurrent pattern of mood episodes and track treatment efficacy¹⁶
assessments that characterize sub-threshold bipolar symptoms, such as the Bipolar Spectrum Diagnostic Scale¹⁷ ( see Box 3 ) and the Bipolarity Index.¹⁸

Also obtain collateral reports from significant others, review patient records, and use the same mania and hypomania scales for prospective assessment as the next spring approaches.⁶

Clinical Point

Characterizing a seasonal mood pattern may allow you and your patient to predict episodes and treat proactively

Assess seasonality in patients with BD to improve diagnosis and treatment. Characterizing a seasonal pattern may allow you and your patient to predict episodes and treat proactively. Commonly used assessments include the SIGH-SAD and the Structured Clinical Interview for DSM Disorders (SCID) seasonal pattern specifier module.¹⁹

The SIGH-SAD measures symptom severity and provides recovery criteria based on changes in scores during treatment. Response is defined as a 50% reduction in symptoms; remission is >50% improvement in SIGH-SAD + HDRS <7 + atypical <7 or HDRS <2 + atypical <10.¹⁴

CASE CONTINUED: Treatment begins

Considering Ms. S’s diagnosis of BD I SP and the risk of precipitating mania with light treatment, we recommend starting treatment with a mood stabilizer. We narrow our options to those that have a direct antidepressant effect, with the hope that this may reduce the need for future antidepressant medications. For patients diagnosed with BD II SP, we could consider a regimen without mood stabilizers.

We offer Ms. S lithium, a first-line mood stabilizer with evidence of usefulness in treatment before chronotherapeutic interventions and in preventing suicidal behavior. However, Ms. S prefers our second option, lamotrigine, because she is concerned about lithium’s side effects and required blood draws to check drug levels as well as thyroid and kidney status.

Despite causing some initial drowsiness, her lamotrigine dosage is successfully titrated after 2 weeks of treatment to 300 mg/d, without side effects. Only then do we initiate light treatment, which Ms. S wishes to try before antidepressant medications. She also begins sessions with a therapist trained in cognitive-behavioral therapy (CBT) for SAD. (For details of this comprehensive treatment, see Box 4 )

Treating bipolar variant of SAD

Significant differences exist in the clinical management of BD SP and MDD SP, despite their commonalities ( Table 2 ). BD SP treatment remains distinct because of the risk of switching with the use of light therapy or antidepressants and the importance of mood stabilizers, especially in BD I.

Consensus guidelines for treating SAD recommend mood stabilizers and close monitoring during light therapy for patients with BD SP ( Table 3 ).² Therapeutic sleep deprivation can quickly reverse depression during hospitalization but is not used often or recommended for outpatient treatment.²⁰

Light therapy. A small body of evidence suggests that depressive symptoms in BD SP improve with bright light therapy, a treatment with demonstrated efficacy in MDD SP.²¹ No differences in response have been reported between light therapy for winter depressive episodes among individuals with BD SP or MDD SP.^22-24 Light therapy may increase the risk of switching to mania/hypomania in patients with BD SP, however. Clinical supervision is imperative, even for patients thought to have MDD SP, because of the risk of undiagnosed BD.

Regular monitoring by a physician is indicated for individuals taking medications or remedies with photosensitizing effects (such as lithium, thioridazine, or St. John’s wort). An ophthalmologist consultation and monitoring is necessary for patients with preexisting eye problems, those taking photosensitizing medications, and those who develop eye problems during light treatment.^2,6

The recommended starting dose for light therapy in MDD SP is 30 minutes daily in the early morning, but this dose may be too high for individuals with BD SP.²⁵ To minimize the risk of switching, begin light therapy at 5 to 10 minutes daily and slowly increase while monitoring the clinical effect (see Related Resources , for more information about light therapy for affective disorders).

Pharmacotherapy. Pharmacologic treatments have not been studied for effectiveness in BD SP, and we hesitate to provide specific recommendations. Effective treatments may include those used for nonseasonal MDD, nonseasonal BD, and MDD SP. When using any medication for BD SP, weigh the risk of switching states against the potential beneficial effects.²