Seasonal affective disorder

Back

1st line –

light therapy

Although patients may not meet criteria for a major depressive disorder, they may still experience significant functional impairment.[55]

No particular treatment is indicated for sub-syndromal clinical presentations. However, evidence-based light therapy may be considered particularly if the patient has significant functional impairment.[56]

Few studies have directly compared light therapy versus antidepressant drugs, although there is limited evidence that light therapy and fluoxetine are equally efficacious.[59][60]

Meta-analyses of randomised controlled trials for light therapy have yielded moderate to large effect sizes.[63][64] Consensus guidelines conclude that light therapy has limited positive evidence from controlled trials.[65][66]

Clinical improvement in symptoms may be observed within 1-3 weeks of consistent administration. If discontinued, symptoms may relapse within 1-3 weeks.[54]

The optimal dosing of light therapy is at least 5000 lux/day, which may involve 2 hours at 2500 lux or 30 minutes of 10,000 lux intensity, during the early morning hours or on rising.

At the point of symptom remission, the dose intensity/duration may be tailored for the remainder of the winter season (e.g., reduced to 15 minutes/day). Therapy is continued until the time of usual symptom remission in the spring or summer. It is re-initiated in early autumn to offset relapse.

Self-reported depression scores have been found to decline after 1 hour of light therapy exposure.[61]

with no comorbid premenstrual dysphoric disorder or anxiety

Back

1st line –

antidepressant therapy

Although patients may not meet criteria for a major depressive disorder, they may still experience significant functional impairment.[55]

No particular treatment is indicated for sub-syndromal clinical presentations. However, antidepressant therapy (selective serotonin-reuptake inhibitors or serotonin-noradrenaline reuptake inhibitors) may be considered particularly if the patient has significant functional impairment.

A National Institute for Health and Care Excellence (NICE) guideline found evidence for antidepressants when used as a prophylactic treatment for seasonal depressive symptoms before they start, whereas evidence was limited for the use of antidepressants once seasonal symptoms have started.[65]

Patients can be encouraged to monitor the intensity, frequency, and duration of seasonal mood symptoms, with particular emphasis on recognising atypical depressive symptoms in the autumn or winter and potential manic or hypomanic symptoms in the spring or summer.

A follow-up evaluation or telephone check within 2-4 weeks to re-assess patient status is recommended.

Antidepressants increase the risk of suicidality in young adults with major depressive or other psychiatric disorders especially during the first months of treatment with antidepressants.[74] Most antidepressant adverse effects are time-limited during dose titration and should be discussed in advance with patients and monitored closely to ensure compliance.

Abruptly discontinuing or rapidly tapering antidepressants can increase the risk of withdrawal symptoms, such as dizziness, irritability, anxiety, restlessness, sweating, nausea, palpitations, and headaches.[65][75] To minimise these risks, a gradual and proportionate tapering schedule with close monitoring is recommended.[65][75] Drugs with a shorter half-life (e.g., paroxetine) should be tapered more slowly. This process may take several months, progressing at a rate that is comfortable for the patient.[76] Withdrawal symptoms can range from mild and transient to prolonged and severe. Close monitoring is necessary to ensure that any withdrawal symptoms do not in fact represent a return of SAD symptoms.[65][75]

Primary options

fluoxetine: 10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

Secondary options

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

paroxetine: 10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments in 4 weeks according to response, maximum 20 mg/day

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 120 mg/day

SAD with recurrent, unipolar depressive disorder

Consider – antidepressant therapy

Back

1st line –

light therapy

Initial treatment is with light therapy or antidepressants. Few studies have directly compared light therapy versus antidepressants, although there is limited evidence that light therapy and fluoxetine are equally efficacious.[59][60]

Clinical improvement in symptoms may be observed within 1-3 weeks of consistent administration. If discontinued, symptoms may relapse within 1-3 weeks.[54]

The optimal dosing of light therapy is at least 5000 lux/day, which may involve 2 hours at 2500 lux or 30 minutes of 10,000 lux intensity, during the early morning hours or on rising. At the point of symptom remission, the dose intensity/duration may be tailored for the remainder of the winter season (e.g., reduced to 15 minutes/day).

Therapy is continued until the time of usual symptom remission in the spring or summer. It is re-initiated in early autumn to offset relapse.

Self-reported depression scores have been found to decline after 1 hour of light therapy exposure.[61]

Back

Consider –

antidepressant therapy

Additional treatment recommended for SOME patients in selected patient group

May be added on to light therapy in people with more severe symptoms or who are more functionally impaired.

May also be added on to light therapy if depressive symptoms do not fully remit during the spring or summer months.

Selective serotonin-reuptake inhibitors (SSRIs), especially fluoxetine and sertraline, have demonstrated efficacy.[59][68][69] In two small randomised trials, fluoxetine had comparable response rates to light therapy.[70] Other SSRIs used to treat major depressive disorders are also likely to be useful, including citalopram and escitalopram.[25][71][72]

Fluoxetine has a long half-life and therefore is least likely to cause withdrawal symptoms, but is more stimulating and may require a slower titration for some patients. Paroxetine has the shortest half-life and is most likely to cause withdrawal symptoms.

Serotonin-noradrenaline reuptake inhibitors, such as duloxetine, have a similar adverse-effect profile to SSRIs and are also likely to be efficacious. However, data are limited.[73]

Primary options

fluoxetine: 10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

Secondary options

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

paroxetine: 10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments in 4 weeks according to response, maximum 20 mg/day

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 120 mg/day

Consider – cognitive behavioural therapy (CBT) and physical activity

Back

Consider –

cognitive behavioural therapy (CBT) and physical activity

Additional treatment recommended for SOME patients in selected patient group

Clinical management can be complicated by sedentary behaviour and social disengagement. Adjunctive use of low-impact physical activity and/or a referral for evidence-based CBT may be indicated in these cases.[58][82]

CBT is a skills-based approach designed to modify thoughts, behaviours, and environmental contingencies that are maintaining or exacerbating symptoms and impairments.

Goals of CBT involve learning strategies to behaviourally manage depressive symptoms, reduce avoidance behaviour, and gradually improve and regain function over time.

In one head-to-head comparison study, CBT and light therapy yielded similar positive outcomes in the acute treatment of SAD.[83] However, longer-term follow-up noted that CBT showed longer-lasting improvements on measures of depressive symptoms than light therapy.[84] Combination therapy of CBT and light therapy has shown to improve symptom outcomes in comparison to light therapy alone.[65]

The referring physician and mental health professional should maintain routine collaboration.

Back

1st line –

antidepressant therapy

Initial treatment is with antidepressants or light therapy. Few studies have directly compared light therapy versus antidepressants, although there is limited evidence that light therapy and fluoxetine are equally efficacious.[59][60]

Few randomised controlled trials studying antidepressant therapy for SAD are available. However, selective serotonin-reuptake inhibitors (SSRIs), especially fluoxetine and sertraline, have demonstrated efficacy.[59][68][69]

Other SSRIs used to treat major depressive disorders are also likely to be useful, including citalopram and escitalopram.[25][71][72] Fluoxetine has a long half-life and therefore is least likely to cause withdrawal symptoms, but is more stimulating and may require a slower titration for some patients. Paroxetine has the shortest half-life and is most likely to cause withdrawal symptoms.

Serotonin-noradrenaline reuptake inhibitors, such as duloxetine, have a similar adverse-effect profile to SSRIs and are also likely to be efficacious. However, data are limited.[73]

Primary options

fluoxetine: 10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

Secondary options

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

paroxetine: 10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments in 4 weeks according to response, maximum 20 mg/day

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 120 mg/day

Consider – cognitive behavioural therapy (CBT) and physical activity

Back

Consider –

light therapy

Additional treatment recommended for SOME patients in selected patient group

May be added on to antidepressant therapy in people with more severe symptoms or who are more functionally impaired.

May also be added on to antidepressants if depressive symptoms do not fully remit during the spring or summer months.

Clinical improvement in symptoms may be observed within 1-3 weeks of consistent administration. If discontinued, symptoms may relapse within 1-3 weeks.[54]

Therapy is continued until the time of usual symptom remission in the spring or summer. It is re-initiated in early autumn to offset relapse.

Self-reported depression scores have been found to decline after 1 hour of light therapy exposure.[61]

Back

Consider –

cognitive behavioural therapy (CBT) and physical activity

Additional treatment recommended for SOME patients in selected patient group

CBT is a skills-based approach designed to modify thoughts, behaviours, and environmental contingencies that are maintaining or exacerbating symptoms and impairments.

Goals of CBT involve learning strategies to behaviourally manage depressive symptoms, reduce avoidance behaviour, and gradually improve and regain function over time.

The referring physician and mental health professional should maintain routine collaboration.

with comorbid premenstrual dysphoric disorder

Back

1st line –

antidepressant therapy

Premenstrual dysphoric disorder has a higher prevalence among patients with SAD than the general population.[13][80]

Although there are no data to guide comorbid treatment, selective serotonin-reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors have been shown to be helpful for each of these disorders separately.[73][78][79]

Primary options

fluoxetine: 10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

Secondary options

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

paroxetine: 10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments in 4 weeks according to response, maximum 20 mg/day

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 120 mg/day

Consider – combined oral contraceptive pill

Back

Consider –

light therapy

Additional treatment recommended for SOME patients in selected patient group

May be added on to antidepressant therapy in people with more severe symptoms or who are more functionally impaired.

May also be added on to antidepressants if depressive symptoms do not fully remit during the spring or summer months.

Meta-analyses of randomised controlled trials for light therapy have yielded moderate to large effect sizes.[63][64]

Clinical improvement in symptoms may be observed within 1-3 weeks of consistent administration. If discontinued, symptoms may relapse within 1-3 weeks.[54]

Therapy is continued until the time of usual symptom remission in the spring or summer. It is re-initiated in early autumn to offset relapse.

Self-reported depression scores have been found to decline after 1 hour of light therapy exposure.[61]

Back

Consider –

combined oral contraceptive pill

Additional treatment recommended for SOME patients in selected patient group

Oral contraceptives are an effective treatment for premenstrual dysphoric symptoms, but they are unstudied in SAD.[81]

Consider – cognitive behavioural therapy (CBT) and physical activity

Back

Consider –

cognitive behavioural therapy (CBT) and physical activity

Additional treatment recommended for SOME patients in selected patient group

CBT is a skills-based approach designed to modify thoughts, behaviours, and environmental contingencies that are maintaining or exacerbating symptoms and impairments.

Goals of CBT involve learning strategies to behaviourally manage depressive symptoms, reduce avoidance behaviour, and gradually improve and regain function over time.

The referring physician and mental health professional should maintain routine collaboration.

Consider – antidepressant therapy

Back

1st line –

light therapy

Light therapy is an alternative first-line therapy to pharmacotherapy. Meta-analyses of randomised controlled trials for light therapy have yielded moderate to large effect sizes.[63][64]

Clinical improvement in symptoms may be observed within 1-3 weeks of consistent administration. If discontinued, symptoms may relapse within 1-3 weeks.[54]

Therapy is continued until the time of usual symptom remission in the spring or summer. It is re-initiated in early autumn to offset relapse.

Self-reported depression scores have been found to decline after 1 hour of light therapy exposure.[61]

Back

Consider –

antidepressant therapy

Additional treatment recommended for SOME patients in selected patient group

May be added on to light therapy in people with more severe symptoms or who are more functionally impaired.

May also be added on to light if depressive symptoms do not fully remit during the spring or summer months.

Primary options

fluoxetine: 10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

Secondary options

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

paroxetine: 10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments in 4 weeks according to response, maximum 20 mg/day

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 120 mg/day

Consider – combined oral contraceptive pill

Back

Consider –

combined oral contraceptive pill

Additional treatment recommended for SOME patients in selected patient group

Oral contraceptives are an effective treatment for premenstrual dysphoric symptoms, but they are unstudied in SAD.[81]

Consider – cognitive behavioural therapy (CBT) and physical activity

Back

Consider –

cognitive behavioural therapy (CBT) and physical activity

Additional treatment recommended for SOME patients in selected patient group

CBT is a skills-based approach designed to modify thoughts, behaviours, and environmental contingencies that are maintaining or exacerbating symptoms and impairments.

Goals of CBT involve learning strategies to behaviourally manage depressive symptoms, reduce avoidance behaviour, and gradually improve and regain function over time.

The referring physician and mental health professional should maintain routine collaboration.

with comorbid anxiety

Consider – antidepressant therapy

Back

1st line –

light therapy

There are no clinical trials assessing the efficacy of light therapy in the management of SAD with comorbid anxiety.

Given the few contraindications for light therapy, it is used as a first-line therapy.

Therapy is continued until the time of usual symptom remission in the spring or summer. It is re-initiated in early autumn to offset relapse.

Self-reported depression scores have been found to decline after 1 hour of light therapy exposure.[61]

Back

Consider –

antidepressant therapy

Additional treatment recommended for SOME patients in selected patient group

There are no clinical trials assessing the efficacy of antidepressant pharmacotherapy in the management of SAD with comorbid anxiety.

Given the established research base for selective serotonin-reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors, these drugs are indicated in some patients in addition to light therapy.

Primary options

fluoxetine: 10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

Secondary options

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

paroxetine: 10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments in 4 weeks according to response, maximum 20 mg/day

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 120 mg/day

Consider – cognitive behavioural therapy (CBT) and physical activity

Back

Consider –

cognitive behavioural therapy (CBT) and physical activity

Additional treatment recommended for SOME patients in selected patient group

CBT is a skills-based approach designed to modify thoughts, behaviours, and environmental contingencies that are maintaining or exacerbating symptoms and impairments.

CBT may be individualised and have a particular emphasis on managing anxiety.

Goals of CBT involve learning strategies to behaviourally manage depressive symptoms, reduce avoidance behaviour, and gradually improve and regain function over time.

The referring physician and mental health professional should maintain routine collaboration.

Back

1st line –

antidepressant therapy

There have been no clinical trials assessing the efficacy of antidepressant pharmacotherapy in the management of SAD with comorbid anxiety.

Given the established research base for selective serotonin-reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors, these drugs are indicated as alternative first-line options to light therapy.

Primary options

fluoxetine: 10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 2-4 weeks according to response, maximum 80 mg/day

sertraline: 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day

Secondary options

citalopram: 10 mg orally once daily initially, increase by 20 mg/day increments every 7 days according to response, maximum 40 mg/day

paroxetine: 10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day

escitalopram: 10 mg orally once daily initially, increase by 10 mg/day increments in 4 weeks according to response, maximum 20 mg/day

duloxetine: 30 mg orally once daily initially, increase by 30 mg/day increments every 2-4 weeks according to response, maximum 120 mg/day

Consider – cognitive behavioural therapy (CBT) and physical activity

Back

Consider –

light therapy

Additional treatment recommended for SOME patients in selected patient group

There are no clinical trials assessing the efficacy of light therapy in the management of SAD with comorbid anxiety.

Given the few contraindications for light therapy, it would be indicated in some patients in addition to antidepressants.

Therapy is continued until the time of usual symptom remission in the spring or summer. It is re-initiated in early autumn to offset relapse.

Self-reported depression scores have been found to decline after 1 hour of light therapy exposure.[61]

Back

Consider –

cognitive behavioural therapy (CBT) and physical activity

Additional treatment recommended for SOME patients in selected patient group

CBT is a skills-based approach designed to modify thoughts, behaviours, and environmental contingencies that are maintaining or exacerbating symptoms and impairments.

CBT may be individualised and have a particular emphasis on managing anxiety.

Goals of CBT involve learning strategies to behaviourally manage depressive symptoms, reduce avoidance behaviour, and gradually improve and regain function over time.

The referring physician and mental health professional should maintain routine collaboration.

SAD with bipolar mood disorder

1st line – mood-stabilising drugs

Back

1st line –

mood-stabilising drugs

All patients with seasonal depression should be screened for spring or summer hypo-mania or mania symptoms. If present, treatment with a mood-stabilising drug is indicated.

Lithium, valproic acid, and some atypical antipsychotics are generally considered first-line mood stabilisers.

Valproic acid (and its derivatives) must not be used in female patients of child-bearing potential unless other options are unsuitable, there is a pregnancy prevention programme in place, and certain conditions are met. Precautionary measures may also be required in male patients owing to a potential risk that use in the 3 months leading up to conception may increase the likelihood of neurodevelopmental disorders in their children. Regulations and precautionary measures for female and male patients may vary between countries, with some countries taking a more heightened precautionary stance, and you should consult your local guidance for more information.

Lithium is toxic at higher levels (>1.5 mmol/L [>1.5 mEq/L]). Older patients may respond at lower doses. Routine serum levels need to be monitored to ensure therapeutic blood levels (0.6 to 1.2 mmol/L [0.6 to 1.2 mEq/L]), and to offset risk for toxicity.

Valproic acid is also toxic at higher levels (>1213 micromol/L [>175 micrograms/mL]). Older patients may respond at lower doses. Routine serum levels need to be monitored to ensure therapeutic blood levels (346 to 867 micromol/L [50 to 125 micrograms/mL]), and to offset risk for toxicity.

Atypical antipsychotic use requires monitoring of weight, pulse, blood pressure, fasting glucose, and lipid profile.

A referral to a psychiatrist for further evaluation and management is recommended. Bipolar disorder can be associated with other psychiatric comorbidities, including substance-use disorders and higher degrees of functional impairments. See Bipolar disorder in adults.

Primary options

lithium: 300 mg (sustained-release) orally twice daily initially, increase gradually according to response and serum drug level, maximum 1800 mg/day

valproic acid: 250 mg orally three times daily initially, increase gradually according to response and serum drug level, maximum 60 mg/kg/day

quetiapine: 50 mg orally (immediate-release) once daily at bedtime initially, increase gradually according to response, maximum 800 mg/day

aripiprazole: 15 mg orally once daily initially, increase gradually according to response, maximum 30 mg/day

olanzapine: 5 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day