Recurrent Major Depressive Disorder With a Seasonal Pattern
Synopsis
Key Points
Recurrent major depressive disorder with a seasonal pattern is diagnosed in patients when symptoms of depression emerge at a particular time of year, usually in winter
Diagnosis is based on the recognition of major depressive episodes occurring at a specific time of the year, causing social or occupational impairment, with the presence of at least 5 of the following symptoms, necessarily including depressed/irritable mood or anhedonia: r1
Depressed mood or irritability for most of the day, and nearly every day, indicated via subjective report of the patient or via observation of others
Anhedonia
Sleep disturbance
Change in weight or appetite
Psychomotor retardation or agitation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to concentrate or indecisiveness
Recurrent thoughts of death, suicidal ideation, suicide attempt, or a specific plan for committing suicide
Must be differentiated from hypothyroidism, major depressive disorder, bipolar disorders I and II, cyclothymic disorder, and substance misuse
Principal treatment modalities consist of light therapy, cognitive behavioral therapy, and selective serotonin reuptake inhibitors
These treatment options can be used in concert as well as individually
In the case of fall/winter seasonality, light therapy is useful not only for treatment, but also as a prevention modality if begun in early fall
Urgent Action
Recognition of suicidal or homicidal ideation is urgent; when present, this warrants immediate referral to a psychiatrist and admission to psychiatric unit
Pitfalls
Failure to recognize the seasonality element of the condition can result in misdiagnosis (eg, cyclothymic disorder), leading to failure to implement effective treatment
Failure to recognize a patient’s suicidal or homicidal risk can lead to tragic consequences of an otherwise manageable condition
Terminology
Clinical Clarification
Recurrent major depressive disorder with a seasonal pattern is a major depressive disorder with a regular temporal relationship between symptomatic episodes and a particular time of the year r2
Classification
DSM-5 TR considers seasonality as an episode specifier for recurrent major depressive disorder r1
Defining characteristic is the onset and remission of episodes of major depressive disorder at characteristic times of the year (usually beginning in fall or winter) r1
Depressive episodes must occur during a particular time of the year with predictable annual recurrence r3
This pattern of onset and remission of episodes must have occurred during at least a 2-year period (ie, 2 depressive episodes must have occurred in the previous 2 years) with no nonseasonal episodes occurring during this period
Seasonal major depressive episodes substantially outnumber the nonseasonal major depressive episodes that may have occurred during individual's life
The seasonal specifier does not apply to when the pattern is better explained by seasonally linked psychosocial stressors (eg, seasonal unemployment)
Recurrent major depressive disorder with a seasonal pattern can be further classified into 2 subtypes, based on the time of year in which episodes occur r2
Winter or fall/winter recurrence
Accounts for the vast majority of cases, especially in populations living at high latitudes
Certain ethnic groups who live at very high latitudes and their descendants may have adapted to long winters and therefore are less prone
A subsyndromal type of seasonal depression, manifesting mostly with sleep disturbances, has been reported among individuals staying at Arctic and Antarctic sites r5
Change in sleep, appetite, or weight (gaining or losing more than 5% body weight within a month, as reported by patient or observed by others) r1c3c4c5
Hypersomnia with hyperphagia, craving for carbohydrates, and weight gain is typical of recurrent major depressive disorder with fall/winter seasonal pattern, as if patient were in a quasi-hibernation state r1c6c7c8
Opposite symptom profile is typical of spring/summer pattern (ie, patient sleeps less, eats less, loses weight) c9c10c11
Seasonal specifier does not apply to those situations in which the pattern is better explained by seasonally linked psychosocial stressors (eg, seasonal unemployment or school schedule)
Depression scales, inventories, and questionnaires r7
Hamilton Depression Rating Scale and Beck Depression Inventory are commonly used c63c64
Laboratory
Laboratory tests play no role in diagnosing the condition, but are used to rule out common conditions, such as substance abuse (urine screen for drugs of abuse) and hypothyroidism (TSH and thyroxine levels) r1c65
Free thyroid hormones (especially free thyroxine) are decreased r16
Usually there is no seasonal pattern or predictable annual occurrence, although seasonal course with summertime improvement has been seen with hypothyroidism r7
Definitive diagnosis is made via thyroid panel (TSH and thyroxine levels) r16
Major depressive disorder without a seasonal pattern r1c69d2
Major depressive disorder is defined by following symptoms, least 5 of which are present nearly every day during the same 2-week period:
Depressed mood most of the day
Markedly reduced interest or pleasure in all or nearly all activities
Change in appetite or weight (increase or decrease)
Sleep disturbance (insomnia or hypersomnia)
Psychomotor agitation or retardation (observable by others)
Fatigue or lack of energy
Reduced ability to think or concentrate; indecisiveness
Feelings of worthlessness or excessive, inappropriate guilt
Recurrent thoughts of death or suicidal ideation or attempt
Symptoms represent a change from usual functioning and cause clinically significant distress or impairment in social, work, or other areas
At least 1 of the symptoms is depressed mood or loss of interest or pleasure
Similar to recurrent major depressive disorder with a seasonal pattern in the history of major depressive episodes defined by presence of 5 or more of the same features; different in that there is no seasonal pattern or predictable annual occurrence
Diagnosis is entirely clinical, based mostly on history
Mood disorder characterized by cycling between depressive and manic or hypomanic episodes
Bipolar I disorder
Criteria have been met for at least 1 manic episode in patient's lifetime
Manic episode may have been preceded by or followed by hypomanic or major depressive episodes
Occurrence of the manic and major depressive episode(s) cannot be better explained by schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum or psychotic disorders
Bipolar II disorder
Criteria have been met for at least 1 hypomanic episode and at least 1 major depressive episode in patient's lifetime
No history of manic episodes
Occurrence of the hypomanic and major depressive episode(s) cannot be better explained by schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum or psychotic disorders
Depressive symptoms or unpredictability caused by frequent alternation between periods of hypomania and depression causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
Similar to recurrent major depressive disorder with a seasonal pattern in that patient meets criteria for at least 1 major depressive episode; different in that there is no seasonal pattern or predictable annual occurrence
Diagnosis is entirely clinical, based mostly on history
Characterized by mood cycling that does not meet diagnostic criteria for major depressive disorder or bipolar disorders I or II
Similar to recurrent major depressive disorder with a seasonal pattern in that major depressive disorder symptoms come and go; different in that there is no seasonal pattern or predictable annual occurrence
Diagnosis is entirely clinical, based mostly on history
Condition resulting from misuse of alcohol or drugs
Similar to recurrent major depressive disorder with a seasonal pattern in that both can manifest with changes in mood, social and occupational impairment, and other similar symptoms
Different in that use of a substance can be identified and established via admission by patient, observation of others, or medical tests (eg, urine screening for drugs of abuse)
Definitive diagnosis is based on history, physical examination, and appropriate substance abuse work-up, which includes:
Questioning regarding quantity of alcohol consumed and/or types and quantities of drugs used
Assays on urine samples for alcohol, opioids, benzodiazepines, cocaine/stimulants, cannabis, and other drugs of abuse
After a positive screening test result, conversation with patient is focused on the substance use to elicit DSM-5 symptoms of a substance use disorder, which include:
Tolerance
Withdrawal
Using more drugs than intended
Failed efforts to cut down or quit
Spending a lot of time related to use
Craving
Failure to fulfill important life roles
Giving up important life activities
Use in hazardous situations
Continued use in spite of either negative physical/psychological problems, or social/interpersonal consequences
Treatment
Goals
Abatement of depression symptoms
Recognition of any suicidal or homicidal potential r6
Identification and management of medical complications of depression, such as malnutrition and nonadherence to medical treatment
Return of patient to normal social/occupational activities and function
Prevention of recurrent episodes
Disposition
Admission criteria
Admission to an inpatient psychiatric unit is warranted when patient cannot care for self or is a danger to self or others, owing to either of the following: r19
Suicidal or homicidal ideation
Previous suicide attempts or violence can strengthen the case for admission when case is equivocal
Presence of psychotic symptoms
Recommendations for specialist referral
Consult psychiatrist for any of the following:
Suicidal or homicidal ideation or attempts
Alcohol or drug dependence or misuse
Comorbid psychosis, suspected bipolar disorder, or personality or developmental disorders
Dementia, delirium, or confusion
Lack of response to light therapy
Treatment Options
Principal treatment modalities consist of the following:
Light therapy (also called bright light therapy) r20
Acceptable treatment option; may have prophylactic benefits for subsequent years
Second generation antidepressant drugs, especially selective serotonergic reuptake inhibitors r22
Second line treatment
Some evidence, albeit limited in quality and quantity, shows effectiveness for fluoxetine and sertraline r22
Light therapy and fluoxetine are comparably effective and well tolerated; other clinical factors, such as patient preference, might guide the selection of treatment r22
Bupropion Hydrochloride Oral tablet, extended release 24 hour [Depression/Mood Disorders]; Adults: Initiate in the autumn with 150 mg PO once daily in the AM; titrate after 7 days to target dose of 300 mg PO once daily in the AM. Continue through winter, then taper and discontinue in early spring. Individualize regimen to patient's historical pattern of SAD episodes. For those receiving 300 mg/day, taper to 150 mg/day prior to discontinuation. Total daily doses above 300 mg/day were not evaluated in SAD clinical trials.
Fluoxetine Hydrochloride Oral tablet [Depression/Mood Disorders]; Adults: 20 mg PO once daily, initially. May increase dose after several weeks if insufficient clinical improvement is observed. May divide doses of 20 mg/day or more in 2 doses. Max: 80 mg/day.
Sertraline Hydrochloride Oral tablet; Adults: 50 mg PO once daily, initially. May increase dose by 25 to 50 mg/day at intervals of at least 1 week as needed. Usual dose: 50 to 200 mg/day. Max: 200 mg/day.
Nondrug and supportive care
The following nondrug therapies have been used to treat this condition: r7
Just after awakening, patient is positioned next to a special light-emitting device to receive 5000 lux hours per day
Usually, this is achieved using a 10,000 lux device for 30 minutes
Patient can engage in any activity while receiving treatment, but must keep eyes within the needed distance from the light source as indicated by the instructions for the particular device
Abatement of major depressive symptoms within a few weeks (usually within 2 weeks) indicates that treatment is effective
Indication
Recurrent major depressive disorder with fall/winter seasonal pattern
Contraindications
Patients with bipolar disorder receiving light therapy are at greater risk of developing manic or hypomanic episodes; however, light therapy is not a contraindication for these patients
Psychological therapy can include counseling or mindfulness based cognitive therapy r24c78
General explanation
Mindfulness based cognitive therapy is highly structured, focused, short-term, and therapist-patient collaborative; consists of the following principal components:
Functional analysis
Patients are taught to recognize irrational thoughts and assumptions, and irrational connections between assumptions, thoughts, and behaviors that underlie, exacerbate, and perpetuate depression
Patients are taught to track, stop, and redirect thoughts with the aim of different behaviors, thereby changing the emotional response that underlies the depression
Skills training
Patients are taught to unlearn behaviors that underlie and exacerbate depression and to learn new behaviors via a variety of techniques, including:
Exposure and desensitization
Learning exercises and home assignments
Adoption of pleasurable activities during the problematic time of the year
Generally, cognitive behavioral therapy shows results in a few weeks or a few months; resolution of depressive symptoms within that time period suggests the treatment has been effective
Indication
Recurrent major depressive disorder with seasonal pattern in any of the following scenarios:
Light therapy is inadequate in abating symptoms
Patient refuses light therapy or is not adherent
Light therapy is not appropriate, owing to nonwinter seasonality of the recurrent depression
Patient is eager to begin cognitive behavioral therapy alongside light therapy
Patients can have a seasonal element (treatable with light therapy) plus depressive features throughout the year, requiring continuous psychotherapy or medication
Anxiety disorders, including obsessive-compulsive disorder c83c84
May alter the plan for any cognitive behavioral therapy, requiring it to be longer or more intense
Can exacerbate or hide the changes in appetite of recurrent major depressive disorder with a seasonal pattern, thereby making the diagnosis more challenging
Depression during pregnancy or the postpartum period c86c87d4
Symptoms of depression are common in the postpartum period, and this period may correlate with the season during which a patient with recurrent depressive disorder suffers symptoms d5
Cognitive behavioral therapy may be the best first option; effects of light therapy during pregnancy are largely unknown
Selective serotonin reuptake inhibitors entail a treatment dilemma: some data show neurobehavioral and long-term cognitive problems among children of women who were treated with those drugs during pregnancy, but untreated maternal depression also carries serious risks for both mother and child
May alter the plan for any cognitive behavioral therapy, requiring it to be longer or more intense
In the case of certain personality disorders, such as borderline personality disorder, presence as a comorbid condition may require dialectic behavioral therapy d6
Dialectic behavioral therapy is a modified form of cognitive behavioral therapy that is focused on changing behaviors that are particularly common in borderline personality disorder (eg, suicidal ideation, self-harm, substance misuse)
Monitoring
Schedule patients for regular follow-up and use a standardized scale to measure response to therapy, as this has been shown to improve outcomes r25
Hamilton Depression Rating Scale or Beck Depression Inventory are useful for monitoring, as are other standardized depression scales (eg, the Patient Health Questionnaire [PHQ-9])
Response to light therapy within 2 weeks of initiation predicts a favorable outcome r14
A meta-analysis supported the efficacy of light therapy in both seasonal and nonseasonal depression, and reported effect sizes that were equivalent to those in most trials of antidepressants r26
Improvement of atypical symptoms (eg, hypersomnolence, increased appetite, carbohydrate craving) after 1 hour of light therapy correlates with improvement of disorder after 2 weeks of therapy r14
Consider initiating light therapy in early fall for patients with fall/winter seasonality r7c96
Evidence supporting light therapy for prevention is limited owing to small studies and methodologic flaws; requires discussion with patient r3
Bupropion is the only medication shown to be effective in preventing recurrence of seasonal affective disorder, but adverse effects, such as headaches, nausea, and insomnia, are commonly observed r9
Lifestyle adjustments are recommended by some experts, including: r7c97
American Psychiatric Association: Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed Text Revision (DSM-5 TR). American Psychiatric Association; 2022:177-214Danilenko KV et al: Seasonal affective disorder. Handb Clin Neurol. 106:279-89, 201222608628Nussbaumer-Streit B et al: Light therapy for preventing seasonal affective disorder. Cochrane Database Syst Rev. 3:CD011269, 201930883670Meesters Y et al: Seasonal affective disorder, winter type: current insights and treatment options. Psychol Res Behav Manag. 9:317-27, 201627942239Arendt J: Biological rhythms during residence in polar regions. Chronobiol Int. 29(4):379-94, 201222497433American Psychiatric Association. Seasonal affective disorder. American Psychiatric Association website. Reviewed October 2020. Accessed October 22, 2022. https://psychiatry.org/patients-families/seasonal-affective-disorderhttps://psychiatry.org/patients-families/seasonal-affective-disorderKurlansik SL et al: Seasonal affective disorder. Am Fam Physician. 86(11):1037-41, 201223198671Nussbaumer-Streit B et al: Melatonin and agomelatine for preventing seasonal affective disorder. Cochrane Database Syst Rev. 6:CD011271, 201931206585Galima SV et al: Seasonal affective disorder: common questions and answers. Am Fam Physician. 102(11):668-72, 202033252911Roecklein KA et al: A missense variant (P10L) of the melanopsin (OPN4) gene in seasonal affective disorder. J Affect Disord. 114(1-3):279-85, 200918804284Øverland S et al: Seasonality and symptoms of depression: A systematic review of the literature. Epidemiol Psychiatr Sci. 29:e31, 201931006406Madsen HØ et al: High prevalence of seasonal affective disorder among persons with severe visual impairment. Br J Psychiatry. ePub, 201526338990Kim YH: Seasonal affective disorder in patients with chronic tinnitus. Laryngoscope. ePub, 201526154998Sher L et al: Early response to light therapy partially predicts long-term antidepressant effects in patients with seasonal affective disorder. J Psychiatry Neurosci. 26(4):336-8, 200111590974Schneibel R et al: Sensitivity to detect change and the correlation of clinical factors with the Hamilton Depression Rating Scale and the Beck Depression Inventory in depressed inpatients. Psychiatry Res. 198(1):62-7, 201222445070Gaitonde D et al: Hypothyroidism: an update. Am Fam Physician. 86(3):244-51, 201222962987Perugi G et al: Cyclothymia reloaded: a reappraisal of the most misconceived affective disorder. J Affect Disord. 183:119-33, 201526005206Merrill JO et al: Addiction disorders. Med Clin North Am. 98(5):1097-122, 201425134875Schoepf D et al: Comorbidity and its relevance on general hospital-based mortality in major depressive disorder: a naturalistic 12-year follow-up in general hospital admissions. J Psychiatr Res. 52:28-35, 201424513499May IC: Light therapy for preventing seasonal affective disorder: summary of a Cochrane review. Explore (NY). 16(2):133-4, 202032111489Rohan KJ et al: Randomized trial of cognitive-behavioral therapy versus light therapy for seasonal affective disorder: acute outcomes. Am J Psychiatry. 172(9):862-9, 201525859764Nussbaumer-Streit B et al: Second-generation antidepressants for treatment of seasonal affective disorder. Cochrane Database Syst Rev. 3:CD008591, 202133661528Cools O et al: Pharmacotherapy and nutritional supplements for seasonal affective disorders: a systematic review. Expert Opin Pharmacother. 19(11):1221-33, 201830048159Forneris CA et al: Psychological therapies for preventing seasonal affective disorder. Cochrane Database Syst Rev. 5:CD011270, 201931124141Guo T et al: Measurement-based care versus standard care for major depression: a randomized controlled trial with blind raters. Am J Psychiatry. 172(10):1004-13, 201526315978Golden RN et al: The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry. 162(4):656-62, 200515800134