The stability of the Seasonal Pattern Assessment Questionnaire score index over time and the validity compared to classification according to DSM-III-R

Enlightened: addressing circadian and seasonal changes in photoperiod in animal models of bipolar disorder

Bipolar disorders (BDs) exhibit high heritability and symptoms typically first occur during late adolescence or early adulthood. Affected individuals may experience alternating bouts of mania/hypomania and depression, with euthymic periods of varying lengths interspersed between these extremes of mood. Clinical research studies have consistently demonstrated that BD patients have disturbances in circadian and seasonal rhythms, even when they are free of symptoms. In addition, some BD patients display seasonal patterns in the occurrence of manic/hypomanic and depressive episodes as well as the time of year when symptoms initially occur. Finally, the age of onset of BD symptoms is strongly influenced by the distance one lives from the equator. With few exceptions, animal models useful in the study of BD have not capitalized on these clinical findings regarding seasonal patterns in BD to explore molecular mechanisms associated with the expression of mania- and depression-like behaviors in laboratory animals. In particular, animal models would be especially useful in studying how rates of change in photoperiod that occur during early spring and fall interact with risk genes to increase the occurrence of mania- and depression-like phenotypes, respectively. Another unanswered question relates to the ways in which seasonally relevant changes in photoperiod affect responses to acute and chronic stressors in animal models. Going forward, we suggest ways in which translational research with animal models of BD could be strengthened through carefully controlled manipulations of photoperiod to enhance our understanding of mechanisms underlying seasonal patterns of BD symptoms in humans. In addition, we emphasize the value of incorporating diurnal rodent species as more appropriate animal models to study the effects of seasonal changes in light on symptoms of depression and mania that are characteristic of BD in humans.

ADHD, circadian rhythms and seasonality

OBJECTIVE

We evaluated whether the association between Adult Attention-Deficit/Hyperactivity Disorder (ADHD) and Seasonal Affective Disorder (SAD) was mediated by the circadian rhythm.

METHOD

Data of 2239 persons from the Netherlands Study of Depression and Anxiety (NESDA) were used. Two groups were compared: with clinically significant ADHD symptoms (N = 175) and with No ADHD symptoms (N = 2064). Sleep parameters were sleep-onset and offset times, mid sleep and sleep duration from the Munich Chronotype Questionnaire. We identified the prevalence of probable SAD and subsyndromal SAD using the Seasonal Pattern Assessment Questionnaire (SPAQ). Clinically significant ADHD symptoms were identified by using a T score>65 on the Conners Adult ADHD Rating Scale.

RESULTS

The prevalence of probable SAD was estimated at 9.9% in the ADHD group (vs. 3.3% in the No ADHD group) and of probable s-SAD at 12.5% in the ADHD group (vs 4.6% in the No ADHD group). Regression analyses showed consistently significant associations between ADHD symptoms and probable SAD, even after adjustment for current depression and anxiety, age, sex, education, use of antidepressants and benzodiazepines (B = 1.81, p < 0.001). Late self-reported sleep onset was an important mediator in the significant relationship between ADHD symptoms and probable SAD, even after correction for confounders (total model effects: B = 0.14, p ≤ 0.001).

CONCLUSION

Both seasonal and circadian rhythm disturbances are significantly associated with ADHD symptoms. Delayed sleep onset time in ADHD may explain the increase in SAD symptoms. Treating patients with SAD for possible ADHD and delayed sleep onset time may reduce symptom severity in these complex patients.

Seasonal pattern of manic episode admissions among bipolar I disorder patients is associated with male gender and presence of psychotic features

BACKGROUND

Bipolar I disorder (BD-I) patients demonstrate disrupted chronobiology expressed as seasonal variation in mood symptoms. The seasonal pattern (SP) specifier of mood disorders was recently extended by the DSM-5, to be applied to manic episodes. However, the significance of seasonality of manic episodes for the course of BD-I is unknown. In the present study we sought to identify clinical and demographic features that discriminate between BD-I patients with and without SP of manic admissions.

METHODS

BD-I patients (n=148) admitted at least twice with the same mood exacerbation type, were retrospectively followed between 2005 and 2013. Demographic and clinical characteristics were compared between BD-I patients with or without SP of manic admissions.

RESULTS

SP of manic episode admissions, found in 31 (26%) of 117 BD-I patients with repeated manic episode admissions, was associated with higher rates of male gender (p=0.01), presence of psychotic features (p=0.01) and comorbid substance use disorder (p<0.05) compared to patients without SP. In a multivariate analysis, SP of manic episode admissions was associated with the presence of psychotic features (OR 8.42, 95% CI: 1.05-67.65, p<0.05) and male gender (OR 3.23, 95% CI: 1.08-9.65, p<0.05), but not with comorbidity of substance use disorder (OR 1.79, 95% CI: 0.71-4.50, p=0.24).

LIMITATIONS

Seasonal psychological/environmental factors contributing to the emergent of mood episodes could not be ruled out.

CONCLUSIONS

Our results suggest that SP of manic admissions is associated with male gender and the presence of psychotic features, thus might be associated with more severe form of the disorder.

Improvement in depression scores after 1 hour of light therapy treatment in patients with seasonal affective disorder

The purpose of this study was to investigate possible rapid effects of light therapy on depressed mood in patients with seasonal affective disorder. Participants received 1 hour of bright light therapy and 1 hour of placebo dim red light in a randomized order crossover design. Depressed mood was measured at baseline and after each hour of light treatment using two self-report depression scales (Profile of Mood States-Depression-Dejection [POMS-D] subscale and the Beck Depression Inventory II [BDI-II]). When light effects were grouped for the two sessions, there was significantly greater reduction in self-report depression scores by -1.3 (p = 0.02) on the BDI-II and -1.2 (p = 0.02) on the POMS-D. A significant but modest improvement was detected after a single active light session. This is the first study, to our knowledge, to document an immediate improvement with light treatment using a placebo-controlled design with a clinical sample of depressed individuals.

Do symptoms of bipolar disorder exhibit seasonal variation? A multisite prospective investigation

OBJECTIVES

Evidence that symptoms of bipolar disorder (BD) vary seasonally is inconclusive. Here, a multisite prospective investigation of patients with BD was used to test the hypothesis that, on average, depressive symptoms peak in autumn/winter and hypo/manic symptoms peak in spring/summer. Secondary analyses explored gender and diagnosis [bipolar I disorder (BD-I) versus bipolar II disorder (BD-II)] effects on seasonality.

METHODS

A sample of 429 patients with BD (61.6% female; 56.2% BD-I) were recruited from 12 sites across Canada. Clinician-rated measures of manic [Young Mania Rating Scale (YMRS), n = 4,753 total observations] and depression symptoms [Montgomery-Åsberg Depression Rating Scale (MADRS), n = 4,691 observations] were taken at scheduled three-month visits as well as any unscheduled visits. At scheduled visits only, Hamilton Depression Rating Scale (Ham-D) assessments (n = 3,153 observations) were also made. Multi-level modeling (MLM) analyses were conducted separately for the three dependent variables and three definitions of Time: calendar month, nominal season, and harmonic analysis.

RESULTS

Primary analyses of the whole sample found that for manic symptoms (YMRS), neither calendar month nor nominal season were significant, and harmonic analyses found an unpredicted frequency two sinusoid, with peaks at 4th December and 4th June (p < 0.018). Secondary analyses found that this sinusoid approximately fit the YMRS data for females and those diagnosed with BD-II. For depression symptoms measured on the MADRS and Ham-D, no significant seasonal patterns were found in primary analyses of the whole sample. Secondary analyses found a significant increase in MADRS scores in November/December among females, but this pattern was not corroborated in nominal season or harmonic analyses.

CONCLUSIONS

No evidence of systematic seasonal variation in symptoms was found in the sample as a whole. Primary analyses found no evidence that hypo/manic symptoms peaked in the lighter months and depressive symptoms peaked in the darker months. The present findings align with broadly negative conclusions from three earlier prospective investigations, and provide the strongest evidence to date that seasonal changes do not in fact cause coordinated variation in BD symptoms.

Delayed sleep phase syndrome is related to seasonal affective disorder

BACKGROUND

Both delayed sleep phase syndrome (DSPS) and seasonal affective disorder (SAD) may manifest similar delayed circadian phase problems. However, the relationships and co-morbidity between the two conditions have not been fully studied. The authors examined the comorbidity between DSPS and SAD.

METHODS

We recruited a case series of 327 DSPS and 331 controls with normal sleep, roughly matched for age, gender, and ancestry. Both DSPS and controls completed extensive questionnaires about sleep, the morningness-eveningness trait, depression, mania, seasonality of symptoms, etc.

RESULTS

The prevalences of SAD and subsyndromal SAD (S-SAD) were higher in DSPS compared to controls (χ(2)=12.65, p=0.002). DSPS were 3.3 times more likely to report SAD (odds ratio, 3.34; 95% CI, 1.41-7.93) compared to controls as defined by the Seasonal Pattern Assessment Questionnaire (SPAQ). Correspondingly, DSPS showed significantly higher seasonality scores compared to controls in mood, appetite, and energy level subscores and the global seasonality score (t=3.12, t=0.002; t=2.04, p=0.041; t=2.64, p=0.008; and t=2.15, p=0.032, respectively). Weight fluctuation during seasons and winter-summer sleep length differences were also significantly higher in DSPS than controls (t=5.16, p<0.001 and t=2.64, p=0.009, respectively). SAD and S-SAD reported significantly higher eveningness, higher depression self-ratings, and more previous mania symptoms compared to non-seasonal subjects regardless of whether they were DSPS or controls.

CONCLUSIONS

These cases suggested that DSPS is partially comorbid with SAD. These data support the hypothesis that DSPS and SAD may share a pathophysiological mechanism causing delayed circadian phase.

What is this thing called “SAD”? A critique of the concept of seasonal affective disorder

Background– Seasonal Affective Disorder (SAD) is supposed to be caused by lack of daylight in winter. Yet the population of Northern Norway, living without sun for two winter months, does not spontaneously complain about depression during the dark period.Aims– To summarize research bearing upon the validity of the concept of SAD.Method– Review of relevant literature concerning the epidemiology of SAD and the questionnaire developed to measure it in general populations, the Seasonal Pattern Assessment Questionnaire (SPAQ).Results– Large population studies from northern Norway do not point to a higher prevalence of depression in winter than expected in any other general population. The psychometric properties of SPAQ are rather poor, and the diagnosis of SAD based on SPAQ bears little relationship to a meaningful concept of depression.Conclusions– Seasonal Affective Disorder is not a valid medical construct. Instead, “Recurrent depression with seasonal pattern” as defined in the DSM-IV and the ICD-10 should be used as terms. However, more research is needed to establish whether it is at all fruitful to single out such a subtype of recurrent depression.

Declaration of Interest: None.

Prevalence of self-reported seasonal affective disorders and the validity of the seasonal pattern assessment questionnaire in young adults Findings from a Swiss community study

BACKGROUND

The objective of this study was to expand the knowledge on the prevalence of self-reported Seasonal Affective Disorder (SAD) and to further study the validity of the Seasonal Pattern Assessment Questionnaire (SPAQ).

METHODS

A total of N=844 young adults were assessed in a Swiss community study by use of the SPAQ, a Seasonal Affective Disorders Questionnaire (SADQ), the Young Adult Self Report (YASR), the Centre for Epidemiologic Depression Scale (CES-D), and scales for measuring self-esteem, self-awareness and life events. At a second stage, a total of N=534 screen positives and controls were subjected to the Composite International Diagnostic Interview (M-CIDI) for the assessment of mental disorders. According to the SPAQ classification a group of SAD subjects and a group of subsyndromal SAD subjects (S-SAD) were defined. In addition, a third group of high-scoring depressives (HSD) subjects scoring above the 75th percentile of the CES-D was defined. Comparisons included these three groups and the rest of the sample serving as controls.

RESULTS

The weighted prevalence for SAD in this sample was 7.84% based on the SPAQ alone. With the addition of the SADQ, weighted prevalence rates dropped to 2.22%. Weighted subsyndromal SAD was 33.04%. Across the vast majority of scales, the SAD group was indistinguishable from the HSD group. These two groups scored highest, whereas the S-SAD group had an intermediate position and the controls had the lowest scores. SAD was best predicted by the CES-D total score.

CONCLUSIONS

The SPAQ as a single measure leads to an overestimation of SAD which, nevertheless, is a rather common phenomenon also in this central European population. The findings on the validity of the SPAQ are extended by showing that predominantly general aspects of depression are measured.

Seasonality is associated with anxiety and depression: the Hordaland health study

BACKGROUND

The purpose of this study was to assess how seasonal changes in mood and behaviour were associated with depression and anxiety symptoms in a sample from a general population, and to investigate how prevalence figures were affected by month of questionnaire completion.

METHODS

The target population included all individuals in the Hordaland county (Norway) born 1953-57 (N=29,400). In total, 8598 men (57% response rate) and 9983 women (70% response rate) attended the screening station. Half of the men (randomly chosen) and all of the women were offered a questionnaire to fill in with items on seasonality. This was measured using the Global Seasonality Score (GSS), a central component of the Seasonal Pattern Assessment Questionnaire (SPAQ). The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression. Both questionnaires were completed by 2980 men (68.9%) and 8074 women (80.9%).

RESULTS

Seasonality was positively associated with levels of both anxiety and depression regardless of the season the interview took place. In subjects with a low/moderate degree of seasonality there were modestly higher levels of depressive symptoms during November through March than the other months.

LIMITATIONS

We had a substantial number of non-responders.

CONCLUSIONS

Our results raise the possibility of seasonality being a separate dimensional trait associated with both anxiety and depression.

Clinical and prognostic implications of seasonal pattern in bipolar disorder: a 10-year follow-up of 302 patients

BACKGROUND

More than 20% of bipolar patients may present with seasonal pattern (SP). Seasonality can alter the course of bipolar disorder. However, to date, long-term follow-up studies of bipolar patients presenting with SP are scarce. We present a 10-year follow-up study comparing clinical and demographic features of bipolar patients with and without SP.

METHOD

Three hundred and twenty-five bipolar I and II patients were followed up for at least 10 years. SP was defined according to DSM-IV criteria. Clinical variables were obtained from structured interviews with the patients and their relatives. Patients with and without SP were compared regarding clinical and sociodemographic variables and a stepwise logistic regression was performed.

RESULTS

Seventy-seven patients (25.5%) were classified as presenting with SP, while 225 (74.5%) were considered as presenting with no significant seasonal variation. Twenty-three patients (7%) were excluded from the study because it was unclear whether they had seasonality or not. There were no differences between groups regarding demographic variables. Patients with SP predominantly presented with bipolar II disorder, depressive onset, and depressive predominant polarity. The greater burden of depression did not correlate with indirect indicators of severity, such as suicidality, hospitalizations or psychotic symptoms.

CONCLUSIONS

Our study links the presence of SP with both bipolar II disorder and predominant depressive component. However, we could not find any difference regarding functionality or hospitalization rates. Modifications in the criteria to define SP are suggested for a better understanding of bipolar disorder.

Dimensionality of the premenstrual syndrome: confirmatory factor analysis of premenstrual dysphoric symptoms among college students

Premenstrual syndrome and premenstrual dysphoric disorder (PMDD) seem to form a severity continuum with no clear-cut boundary. However, since the American Psychiatric Association proposed the research criteria for PMDD in 1994, there has been no agreement about the symptomatic constellation that constitutes this syndrome. The objective of the present study was to establish the core latent structure of PMDD symptoms in a non-clinical sample. Data concerning PMDD symptoms were obtained from 632 regularly menstruating college students (mean age 24.4 years, SD 5.9, range 17 to 49). For the first random half (N = 316), we performed principal component analysis (PCA) and for the remaining half (N = 316), we tested three theory-derived competing models of PMDD by confirmatory factor analysis. PCA allowed us to extract two correlated factors, i.e., dysphoric-somatic and behavioral-impairment factors. The two-dimensional latent model derived from PCA showed the best overall fit among three models tested by confirmatory factor analysis (chi(2)53 = 64.39, P = 0.13; goodness-of-fit indices = 0.96; adjusted goodness-of-fit indices = 0.95; root mean square residual = 0.05; root mean square error of approximation = 0.03; 90%CI = 0.00 to 0.05; Akaike's information criterion = -41.61). The items "out of control" and "physical symptoms" loaded conspicuously on the first factor and "interpersonal impairment" loaded higher on the second factor. The construct validity for PMDD was accounted for by two highly correlated dimensions. These results support the argument for focusing on the core psychopathological dimension of PMDD in future studies.

A follow up study of seasonality in affective disorders: A preliminary study

BACKGROUND

Researchers have evinced interest in the effect of seasonality on certain behavioural and emotional disorders, the most prominent being Affective Disorders.

AIM

To assess the pattern of seasonality and the clinical course in cases of affective disorder in a tertiary care psychiatric centre in North India.

MATERIALS AND METHODS

Thirteen patients diagnosed as cases of affective disorder as per ICD- 10 DCR (F30-39) were re-assessed using seasonal pattern assessment questionnaire (SPAQ) after a period of 5-7 years.

RESULTS

Majority of the patients (53.8%) were males. Recurrent depressive disorder current episode moderate with/without somatic syndrome was the commonest current diagnosis as per ICD-10 DCR. Mean global seasonality score was 3.46 (S.D, 6.55; range 1-24) as assessed by SPAQ. Most of the patients did not report any variation in mood, behaviour, sleep pattern and weight fluctuations.

CONCLUSIONS

It has been demonstrated that manifestation of an affective disorder is not necessarily associated with high seasonality change.

Seasonal variations in mood and behaviour associated with gender, annual income and education: the Hordaland Health Study

OBJECTIVE

To explore the relationship between demographic factors and seasonal changes in mood and behaviour.

METHOD

A health survey was conducted among 40-45 year old inhabitants in Hordaland County, Norway. The Global Seasonality Score, investigating seasonal symptoms, was given to 4299 men and 9983 women. Response rates among those receiving the questionnaire were 79.8% for men (n = 3432) and 81.2% for women (n = 8223).

RESULTS

High seasonality was reported by 18.4% of men and 22.2% of women. Female gender, low educational level, high level of affective symptomatology and low household income correlated with high seasonality. Among men, being single was also a determinant factor for high seasonality. Reported seasonality also depended on which month the questionnaire was filled in.

CONCLUSIONS

In this study, high seasonality was most prevalent among females, being single, having a low annual income and a low education level. The latter two findings are different from expectations which could be drawn from previous studies suggesting an opposite association.

The diagnosis, symptomatology, and epidemiology of seasonal affective disorder

The operational criteria for seasonal affective disorder (SAD) have undergone several changes since first proposed in 1984. SAD is currently included as a specifier of either bipolar or recurrent major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The International Classification of Diseases, Tenth Edition has provisional diagnostic criteria for SAD. The most characteristic quality of SAD is that the symptoms usually present during winter and remit in the spring. Furthermore, the symptoms tend to remit when the patients are exposed to daylight or bright light therapy. The cognitive and emotional symptoms are as in other types of depression but the vegetative symptoms are the reverse of classic depressive vegetative symptoms, namely increased sleep and increased appetite. SAD is a common condition, but the exact prevalence rates vary between different studies and countries and is consistently found to be more common in women and in youth. SAD probably possibly occurs in children although not as commonly as in young adults. Some studies have found that certain ethnic groups who live at high northern latitudes may have adapted to the long arctic winter.

Adjunctive bright light in non-seasonal major depression

OBJECTIVE

Bright light treatment is an established treatment for Seasonal Affective Disorder, but in non-seasonal depression research results have been contrasting.

METHOD

This study was designed as a 5-week controlled, double-blind, parallel trial in out-patients with a diagnosis (DSM-IV) of non-seasonal major depression, randomized to either active treatment (white light, 10 000 lux, 1 h daily) or placebo treatment (red light, 50 lux, 30 min daily) and concomitant treatment with sertraline in both groups.

RESULTS

One hundred and two patients were included in the study. Analyses showed that on all used scales the reduction in depression scores was larger in the bright light group than in the dim light group, and this reached statistical significance on all observer rating scales and on the SCL-90R self-assessment scale. The HAM-D6 was the most sensitive scale to measure improvement at endpoint.

CONCLUSION

The study results support the use of bright light as an adjunct treatment to antidepressants in non-seasonal depression.

Premenstrual dysphoric symptoms amongst Brazilian college students: factor structure and methodological appraisal

OBJECTIVES

The present study aims to assess the factor structure of the DSM-IV Premenstrual Dysphoric Disorder (PMDD) symptoms and its relationship with depressive symptoms.

METHODS

We evaluated retrospectively PMDD symptoms in 513 female college students, through a self-reporting questionnaire based on DSM-IV criteria, in addition to the Beck Depression Inventory (BDI). Principal component analysis on PMDD symptom data was performed to assess its dimensional structure.

RESULTS

In this non-clinical sample, the analysis indicated a higher importance of the dysphoric dimension, but physical symptoms as well as "being out of control" or "overwhelmed" should also be viewed as major symptoms of PMDD. Behavioural symptoms are of secondary importance. The mean BDI score of PMDD group was significantly higher (p < 0.05) than non-PMDD group.

CONCLUSION

The factor structure of the total sample was similar to the symptom structure suggested by DSM-IV diagnostic criteria. Depressive symptoms should be viewed as a confounding variable in PMDD.