Evidence-Based Reviews

SAD: Is seasonal affective disorder a bipolar variant?

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

References

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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.

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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.

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14. Terman M, Terman J, Rafferty B. Experimental design and measures of success in the treatment of winter depression by bright light. Psychopharmacol Bull. 1990;26(4):505-510.

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.

16. Denicoff KD, Leverich GS, Nolen WA, et al. Validation of the prospective NIMH-Life-Chart Method (NIMH-LCM-p) for longitudinal assessment of bipolar illness. Psychol Med. 2000;30:1391-1397.

17. Ghaemi SN, Miller CJ, Berv DA, et al. Sensitivity and specificity of a new Bipolar Spectrum Diagnostic Scale. J Affect Disord. 2005;84:273-277.

18. Phelps J, Angst J, Katzow J, et al. Validity and utility of bipolar spectrum models. Bipolar Disord. 2008;10:179-193.

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.

22. Terman M, Terman JS, Ross DC. A controlled trial of timed bright light and negative air ionization for treatment of winter depression. Arch Gen Psychiatry. 1998;55(10):875-882.

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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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30. Rohan KJ, Roecklein KA, Tierney Lindsey K, et al. A randomized controlled trial of cognitive-behavioral therapy, light therapy, and their combination for seasonal affective disorder. J Consult Clin Psychol. 2007;75(3):489-500.

31. Rohan KJ. Coping with the seasons: a cognitive-behavioral approach to seasonal affective disorder. Therapist guide. New York, NY: Oxford University Press; 2008.

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Physiopathologic findings and clinical management for SAD vs BD

	SAD	BD
Differences	May be unipolar or bipolar Defined by seasonality Light therapy and antidepressants indicated	Increased risk of psychosis and psychiatric hospitalization Most BD is not seasonal Mood stabilizers indicated Risk of switching states with light therapy and antidepressants
Similarities	Atypical depressive symptom presentation Highly recurrent Predictable season of recurrence allows proactive treatment Assess for mania and hypomania in both disorders Light therapy requires clinical supervision Psychotherapy may be beneficial
BD: bipolar disorder; SAD: seasonal affective disorder

Table 3

Recommended treatment for bipolar disorder with seasonal pattern

Treatment	Recommendation
Mood-stabilizing medications	Maintain year-round, especially in patients with BP I
Antidepressants	Consider those with efficacy in unipolar SAD or nonseasonal bipolar depression
Light therapy	Initiate for 5 to 10 min/day for bipolar depressive episodes in patients receiving mood stabilizers or atypical antipsychotics; slowly increase duration while monitoring mood, sleep, and side effects to manage risk of hypomanic or manic switch
Psychotherapy	Consider CBT or interpersonal and social rhythm therapy to help manage symptoms and reduce episode recurrence
BP I: bipolar disorder type I; CBT: cognitive-behavioral therapy; SAD: seasonal affective disorder

CASE CONCLUSION: Ongoing treatment required

Clinical Point

Approximately one-half of patients who undergo CBT for SAD do not experience another episode the winter after treatment

After several months of light therapy, Ms. S begins to feel better and reports having more energy. We taper her light therapy to 10 minutes daily in the morning from late February until 1 week after daylight saving time begins in mid-March. Weekly phone calls during this transition screen for signs of hypomania or mania. Lamotrigine is effective in preventing switches in spring.

Future plans include monitoring for hypomania through summer and possibly reinitiating light therapy in fall or winter. Because approximately one-half of individuals who undergo CBT for SAD do not experience another episode the winter after treatment, light therapy will be initiated only if depressive symptoms emerge. A booster session is scheduled with Ms. S’s CBT therapist in early fall to reinforce relapse prevention skills.

Clinical Point

Antidepressant therapy is recommended if full response is not maintained with light therapy and CBT skills for SAD

Antidepressant therapy will be recommended if full treatment response is not maintained with light therapy and continued use of CBT skills for SAD. During sessions, we emphasize compliance with lamotrigine. On several occasions Ms. S questions the need for ongoing therapy, but with education about the potential effects of mania she agrees to continue treatment as indicated.

Related resources

Seasonality screening tools

Seasonal Pattern module of the Structured Clinical Interview for DSM Disorders (SCID). www.scid4.org/faq/clinician_version.html.
Hypomania Interview Guide for Seasonal Affective Disorder (HIGH-SAD). www.chronotherapeutics.org/Tools_ENG.html.
National Institutes of Health Life Chart Method. www.bipolarnews.org/Clinician%20Life%20Charting.htm.
Structured Interview Guide for the Hamilton Depression Rating Scale—Seasonal Affective Disorder Version (SIGH-SAD). www.chronotherapeutics.org/Tools_ENG.html.

Bipolarity screening tools

Bipolar Spectrum Diagnostic Scale. Click here to download.
Bipolarity Index. http://psycheducation.org/depression/STEPBipolarityIndex.htm.

Light therapy

Wirz-Justice A, Benedetti F, Terman M. Chronotherapeutics for affective disorders: a clinician’s manual for light and wake therapy. Basel, Switzerland: S. Karger AG; 2009.
Wirz-Justice A, Benedetti F, Berger M, et al. Chronotherapeutics (light and wake therapy) in affective disorders. Psychol Med. 2005;35(7):939-944.

Psychotherapy

Rohan KJ. Coping with the seasons: a cognitive-behavioral approach to seasonal affective disorder (therapist guide). New York, NY: Oxford University Press; 2008.
Frank E. Treating bipolar disorder: a clinician’s guide to interpersonal and social rhythm therapy. New York, NY: Guilford Press, Inc.; 2005.

Drug brand names

Aripiprazole • Abilify
Bupropion • Wellbutrin XL
Carbamazepine • Tegretol
Citalopram • Celexa
Fluoxetine • Prozac
Lamotrigine • Lamictal
Lithium • Eskalith, Lithobid
Quetiapine • Seroquel
Sertraline • Zoloft
Thioridazine • Mellaril
Valproate • Depakote

Disclosures

Drs. Roecklein and Rohan report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Postolache received an investigator-initiated award from The LiteBook Company (Vancouver, Canada) via the Society for Light Treatment and Biological Rhythms, as well as research support from Apollo Health (Salt Lake City, UT).