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Nov.15.2021

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 considers seasonality as an episode specifier for recurrent major depressive disorder r1
    • Symptoms must be present most days, throughout most of the day, during the same 2-week period and must include at least 1 of the following:
      • Depressed mood or irritability nearly every day, indicated via subjective report of the patient or via observation made by others
      • Anhedonia
    • In addition to 4 of the following:
      • Sleep disturbance
      • Change in weight or appetite
      • Change in usual amount of activity (psychomotor retardation or agitation), as reported by patient or observed by others
      • 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
    • Mnemonic device SIG E CAPS can be helpful to remember symptoms other than mood: r3
      • Sleep changes
      • Decreased Interest (anhedonia)
      • Increased feelings of Guilt
      • Decreased Energy
      • Impaired Concentration
      • Appetite changes
      • Psychomotor changes
      • Suicidal thoughts or actions
    • Symptoms are associated with impaired social or occupational function, and cannot be attributed to physiologic effects of a substance or medical disorder
    • Depressive episodes must occur during a particular time of the year with predictable annual recurrence r4
    • 2 depressive episodes must have occurred in the previous 2 years, without patient having experienced any nonseasonal depressive episodes during that period
  • 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
    • Summer or spring/summer recurrence
      • Constitutes only a minority of cases r5
  • A subsyndromal type of seasonal depression, manifesting mostly with sleep disturbances, has been reported among individuals staying at Arctic and Antarctic sites r6

Diagnosis

Clinical Presentation

History

  • Seasonal pattern of symptoms r7
  • Any of the following symptoms or complaints are common:
    • Decline in performance at work or school c1c2
    • 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 and weight gain is typical of recurrent major depressive disorder with fall/winter seasonal pattern, as if patient were in a quasi-hibernation state c6c7c8c9c10c11
      • Opposite symptom profile is typical of spring/summer pattern (ie, patient sleeps less, eats less, loses weight) c12c13c14c15c16c17
    • Fatigue c18
    • Loss of interest in sexual activity c19
    • Headache or other pain c20
    • Concentration difficulty, indecisiveness, or memory impairment c21c22c23
    • Nausea c24
    • Change in bowel habits (constipation or diarrhea) c25c26c27
    • Craving for carbohydrates c28
    • Difficulty with morning awakening c29
  • Additional symptoms that may be present include:
    • Anxiety or worry c30c31
    • Suicidal ideation or thoughts of death c32
    • Feelings of guilt or worthlessness c33c34
    • Preoccupation with physical discomfort c35
    • Symptoms of psychosis (eg, delusions, hallucinations) c36c37c38

Physical examination

  • Physical findings can include:
    • Weight changes or, in the case of children, not meeting expected weight gain c39
    • Signs of self-abuse (eg, scars, bruises, lacerations) c40c41c42c43
  • Psychiatric signs
    • Any of the following types of abnormal affect:
      • Blunted (flat) or constricted c44c45
      • Irritable c46
      • Labile c47
      • Inappropriate c48
    • Abnormal psychomotor activity is often seen
      • Psychomotor retardation c49
        • Indicated by slowed or absent spontaneous movement c50
        • Typical of the fall/winter pattern c51c52
      • Psychomotor agitation c53
        • Patient appears restless

Causes and Risk Factors

Causes

  • Condition is thought to be caused by combination of factors that likely include: r8
    • Circadian phase delay or advance, probably affecting depressive symptoms via changes in melatonin levels c54
    • Self prescribed medications that can be ineffective and/or cause side effects (such as melatonin) r9
    • Abnormal retinal sensitivity to light c55
    • Neurotransmitter dysfunction c56
    • Genetic variations affecting circadian rhythms
    • Abnormal serotonin levels c57

Risk factors and/or associations

Age
  • Higher risk from age 18 to 30 years r10c58
Sex
  • More common in women, with reported female to male ratio of 4 to 1 r8c59
Genetics
  • Variants of the melanopsin gene (OPN4) could predispose some individuals r11c60
  • Having a first-degree relative who has experienced depressive symptoms increases the risk r10c61
Other risk factors/associations
  • Residence at mid to high latitudes r12c62
  • Severe visual impairment r13c63
  • Chronic tinnitus r14c64

Diagnostic Procedures

Primary diagnostic tools

  • History and physical examination r8c65
  • Depression scales, inventories, and questionnaires r8
    • Hamilton Depression Rating Scale and Beck Depression Inventory are commonly used

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) r1

Other diagnostic tools

  • Hamilton Depression Rating Scale r15c66
    • Recurrent major depressive disorder with a seasonal pattern is designated seasonal affective disorder on this scale
    • Completed by examiner while observing patient
  • Beck Depression Inventory r16c67
    • Questionnaire answered by patient
    • Available in standard 21-question format, or as an abridged 7-question format appropriate for screening in the primary care setting
    • Elucidates severity, intensity, and depth of typical major depression symptoms

Differential Diagnosis

Most common

  • Hypothyroidism c68d1
    • Disorder characterized by inadequate synthesis and secretion of thyroid hormones r17
    • Similarities r17
      • Patient has low energy or fatigue and may have depressed mood
      • Hypophagia
      • Weight gain
      • Hypersomnia
    • Differences
      • TSH level is elevated r17
      • Free thyroid hormones (especially free thyroxine) are decreased r17
      • Usually there is no seasonal pattern or predictable annual occurrence, although seasonal course with summertime improvement has been seen with hypothyroidism r8
    • Definitive diagnosis is made via thyroid panel (TSH and thyroxine levels) r17
  • Major depressive disorder without a seasonal pattern r1c69d2
    • Disorder defined by presence of depressed/irritable mood and/or anhedonia, plus 4 or more of the following features for at least 2 consecutive weeks:
      • Sleep changes
      • Decreased interest (anhedonia)
      • Increased feelings of guilt
      • Decreased energy
      • Impaired concentration
      • Appetite changes
      • Psychomotor changes
      • Suicidal thoughts or actions
    • 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
  • Bipolar disorder r1c70d3
    • Mood disorder characterized by cycling between depressive and manic or hypomanic episodes
      • Bipolar I includes manic episodes, with an episode defined by the following criteria:
        • Persistent elevated, expansive, or irritable mood for at least 1 week (or less than 1 week if hospitalization is required)
        • 3 or more of the following symptoms present during mood disturbance (4 or more required if mood is irritable and not elevated or expansive):
          • Inflated self-esteem or grandiosity
          • Decreased need for sleep
          • Increased talkativeness
          • Flight of ideas or racing thoughts
          • Distractibility
          • Increase in goal-directed activity or psychomotor agitation
          • Increase in risky behavior
        • Symptoms don’t meet criteria for a mixed episode, in which both manic and major depressive episode criteria are present
        • Level of severity sufficient to cause social or occupational impairment, hospitalization, or psychotic features
        • Symptoms are not due to substance use or a medical condition
      • Bipolar II includes hypomanic episodes
        • Hypomanic episode is defined by same criteria that define a manic episode, except level of severity is not sufficient to cause social or occupational impairment, hospitalization, or psychotic features
    • 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
  • Cyclothymic disorder r18c71
    • 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
  • Substance-related disorder r19c72
    • 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 r7
  • 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: r20
    • 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) r21
    • Primary treatment modality
  • Cognitive behavioral therapy r22
    • Efficacy is comparable with light therapy
    • Acceptable treatment option; may have prophylactic benefits for subsequent years
  • Second generation antidepressant drugs, especially selective serotonergic reuptake inhibitors r23
    • Second line treatment
    • Some evidence, albeit limited in quality and quantity, shows effectiveness for fluoxetine and sertraline r23
      • Light therapy and fluoxetine are comparably effective and well tolerated; other clinical factors, such as patient preference, might guide the selection of treatment r23

Drug therapy

  • Selective serotonin reuptake inhibitors r10c73
    • Bupropion (extended-release bupropion hydrochloride tablets; e.g., Wellbutrin XL): r24
      • 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 r10c74
      • Fluoxetine Hydrochloride Oral tablet [Depression/Mood Disorders]; Adults: 20 mg/day PO initially. May increase after several weeks by 10 to 20 mg as needed and tolerated. Consider lower dosages for geriatric adults. Max: 80 mg/day PO. May divide daily dose into 2 doses (e.g., morning and noon) if the dosage is 20 mg/day or more.
    • Sertraline r10c75
      • Sertraline Hydrochloride Oral tablet; Adults: 50 mg PO once daily. A lower initial dose (25 mg PO once daily) may be used to minimize adverse effects. May increase at intervals of not less than 1 week. May initiate sertraline capsules in patients who have taken 100 mg or 125 mg for at least 1 week. Max: 200 mg/day PO.

Nondrug and supportive care

The following nondrug therapies have been used to treat this condition: r8

  • Light therapy
  • Cognitive behavioral therapy
Procedures
Light therapy r21c76
General explanation
  • 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 r25c77
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

Comorbidities

  • Major psychiatric disorders c78
    • Bipolar disorders I and II c79c80d3
      • Typically require additional treatment alongside light therapy or cognitive behavioral therapy
    • Cyclothymic disorders c81
      • 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 c82c83
      • May alter the plan for any cognitive behavioral therapy, requiring it to be longer or more intense
    • Eating disorders c84
      • 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 c85c86d4
      • 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
  • Personality and developmental disorders c87c88d6
    • 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 r26
    • 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])

Complications and Prognosis

Complications

  • Suicide r7c89
  • Impaired social and occupational performance c90c91
  • Disrupted interpersonal relations c92
  • Substance misuse c93

Prognosis

  • Response to light therapy within 2 weeks of initiation predicts a favorable outcome r15
  • 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 r27
  • 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 r15

Screening and Prevention

Screening c94

Prevention

  • Consider initiating light therapy in early fall for patients with fall/winter seasonality r8c95c96
    • Evidence supporting light therapy for prevention is limited owing to small studies and methodologic flaws; requires discussion with patient r4
  • 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 r10
  • Lifestyle adjustments are recommended by some experts, including: r8c97
    • Exercising more often c98
    • Increasing light in the home c99
    • Practicing relaxation and stress management techniques c100c101
    • Spending more time outside c102
    • Visiting sunnier, warmer climates c103
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