Treatment of seasonal affective disorder: a review

Circadian rhythms-related disorders in diurnal fat sand rats under modern lifestyle conditions: A review

Modern lifestyle reduces environmental rhythmicity and may lead to circadian desynchrony. We are exposed to poor day-time lighting indoors and excessive night-time artificial light. We use air-conditioning to reduce ambient temperature cycle, and food is regularly available at all times. These disruptions of daily rhythms may lead to type 2 diabetes mellitus (T2DM), obesity, cardiometabolic diseases (CMD), depression and anxiety, all of which impose major public health and economic burden on societies. Therefore, we need appropriate animal models to gain a better understanding of their etiologic mechanisms, prevention, and management.We argue that the fat sand rat (Psammomys obesus), a diurnal animal model, is most suitable for studying the effects of modern-life conditions. Numerous attributes make it an excellent model to study human health disorders including T2DM, CMD, depression and anxiety. Here we review a comprehensive series of studies we and others conducted, utilizing the fat sand rat to study the underlying interactions between biological rhythms and health. Understanding these interactions will help deciphering the biological basis of these diseases, which often occur concurrently. We found that when kept in the laboratory (compared with natural and semi-wild outdoors conditions where they are diurnal), fat sand rats show low amplitude, nocturnal or arrhythmic activity patterns, dampened daily glucose rhythm, glucose intolerance, obesity and decreased survival rates. Short photoperiod acclimation exacerbates these pathologies and further dampens behavioral and molecular daily rhythms, resulting in CMD, T2DM, obesity, adipocyte dysfunction, cataracts, depression and anxiety. Increasing environmental rhythmicity by morning bright light exposure or by access to running wheels strengthens daily rhythms, and results in higher peak-to-trough difference in activity, better rhythmicity in clock genes expression, lower blood glucose and insulin levels, improved glucose tolerance, lower body and heart weight, and lower anxiety and depression. In summary, we have demonstrated that fat sand rats living under the correspondent of “human modern lifestyle” conditions exhibit dampened behavioral and biological rhythms and develop circadian desynchrony, which leads to what we have named “The Circadian Syndrome”. Environmental manipulations that increase rhythmicity result in improvement or prevention of these pathologies. Similar interventions in human subjects could have the same positive results and further research on this should be undertaken.

Investigation on the influence of isolated environment on human psychological and physiological health

Crewmembers are working and living in isolated environment lacking natural light and perception. Although their health problems have been documented, the mechanism has not been thoroughly investigated. The aim of the present study is to investigate the psychological and physiological influences of isolated environment on crewmember's health. On account of complexity of the isolated environment, it is necessary to have a manually controllable system to simulate research platform-Bioregenerative Life Support System (BLSS). Symptom checklist 90 (SCL-90) was used to complete emotional status test. Urine samples were collected for metabonomics and hormone secretion analysis. Fecal samples were collected for intestinal microorganisms analysis. Crewmembers (n = 4) followed strict daily schedule during the experimental period. Five emotional factors were significantly (P < 0.05) increased, differential metabolites were enriched in tryptophan metabolism pathway, the relative abundance of Prevotella decreased significantly (P < 0.0001) when crewmembers in isolated environment without natural light. Hormone (melatonin, cortisol) secretion rhythm also changed. Significant positive correlation (r = 0.805, P < 0.05) between cortisol secretion and anxiety was observed. In conclusion, natural light simulation in an isolated environment may have a positive effect on the physiological and psychological health of the crewmember.

Seasonal affective disorder

Seasonal affective disorder (SAD) is a recurrent depressive disorder in which episodes occur at a particular time of year. The most frequent variant is winter SAD in which patients become depressed during the autumn or early winter, with remission or conversion to hypomania the following spring. Recognition of winter SAD is important because the diagnosis predicts a good response to the novel treatment of phototherapy. One other variant, summer SAD, has also been described and we will discuss this condition separately. Otherwise, we will confine our discussion to the winter variant which we will refer to as SAD.

FORMAL AND MODEL DRIVEN DESIGN OF THE BRIGHT LIGHT THERAPY SYSTEM LUXAMET

Seasonal depression seriously diminishes the quality of life for many patients. To improve their condition, we propose LUXAMET, a bright light therapy system. This system has the potential to relieve patients from some of the symptoms caused by seasonal depression. The system was designed with a formal and model driven design methodology. This methodology enabled us to minimize systemic hazards, like blinding patients with an unhealthy dose of light. This was achieved by controlling race conditions and memory leaks, during design time. We prove that the system specification is deadlock as well as livelock free and there are no invariant violations. These proofs, together with the similarity between specification model and implementation code, make us confident that the implemented system is a reliable tool which can help patients during seasonal depression.

Psychiatric and addictive symptoms of young adult female indoor tanners

PURPOSE

Indoor tanning (IT) increases risk for melanoma and is particularly common among young adult women. IT has also been linked with some psychiatric symptoms, and frequent tanning may indicate tanning dependence (addiction) associated with endorphin release during ultraviolet radiation exposure. The objective of the current study was to investigate associations between IT, tanning dependence, and psychiatric and substance use symptoms in young adult women.

DESIGN

Cross-sectional survey and psychiatric interview.

SETTING

Online, except for the Mini International Neuropsychiatric Interview (MINI), which was completed over the telephone.

SUBJECTS

Participants were 306 female university students aged 18 to 25 years.

MEASURES

MINI, Seasonal Scale Index, tanning dependence scales, reporting ever having used a tanning bed or booth with tanning lamps (single item), reporting smoking a cigarette in the last 30 days (single item).

ANALYSIS

Descriptive statistics, χ(2) analysis, multivariate logistic regression.

RESULTS

Forty-six percent of the sample reported a history of IT, and 25% were classified as tanning dependent. Multivariate logistic regression analyses showed that IT was significantly associated with symptoms of alcohol use disorders, generalized anxiety, and not having social anxiety. Tanning dependence was associated with symptoms of alcohol use disorders.

CONCLUSION

Tanning is of concern not only for its association with skin cancer but for its association with psychiatric and substance use symptoms. Young women with certain psychological problems may seek relief from their symptoms by IT. These findings suggest that indoor tanners may benefit from health behavior and other psychosocial interventions.

Short wavelength light administered just prior to waking: a pilot study

Bright light in the blue-green range, administered in the early morning hours (prior to waking) may be particularly effective in shifting circadian rhythms and may increase gonadotropin production. Accordingly, we tested the feasibility and utility of a mask that emits bright blue/green light (compared to a similar mask that emitted a dim red light) towards the end of sleep in a randomized, placebo-controlled pilot study. The study included a 3-day baseline period, immediately followed by a 12-day intervention period. Subjects were 30 healthy young men with minimal-mild depression. The bright light masks were well-tolerated and demonstrated adequate safety and feasibility. Following the intervention, those who wore the bright light mask demonstrated altered sleep timing suggestive of an earlier sleep period, and excreted a slight increase in follicle-stimulating hormone. Overall, light masks may prove useful in future studies of bright light therapy.

Bright light therapy protects women from circadian rhythm desynchronization during chemotherapy for breast cancer

Circadian rhythms (CRs) are commonly disrupted in women undergoing chemotherapy for breast cancer (BC). Bright light improves and strengthens CRs in other populations. This randomized controlled study examined the effect of morning administration of bright light therapy on CRs in women undergoing chemotherapy for BC. It was hypothesized that women receiving bright light therapy would exhibit more robust rhythms than women exposed to dim light. Thirty-nine women newly diagnosed with BC and scheduled for chemotherapy were randomized into 2 groups: bright white light (BWL) or dim red light (DRL). Women were instructed to use the light box every morning for 30 min during their first 4 cycles of chemotherapy. Wrist actigraphy was recorded at 5 time points: prior to chemotherapy (baseline), Cycle-1 treatment week (C1TW), Cycle-1 recovery week (C1RW), Cycle-4 treatment week (C4TW), and Cycle-4 recovery week (C4RW). There was a Group × Time interaction at C4TW compared to baseline such that the DRL group showed significant deterioration in the mean of the activity rhythm (mesor) and amplitude, whereas the BWL group exhibited a significant increase in both mesor and amplitude. The DRL group also exhibited significant deterioration in overall rhythm robustness at C1TW, C4TW, and C4RW. Women in the BWL group also showed significant decreases in overall rhythm robustness at C1TW and C4TW, but returned to baseline levels at both recovery weeks. The results suggest that morning administration of bright light may protect women from experiencing CR deterioration during chemotherapy.

Effectiveness of light therapy for depression among active duty service members: A nonrandomized controlled pilot trial

OBJECTIVE

The authors investigated the potential effectiveness of light therapy as an augmentation treatment for depression among active duty service members.

DESIGN

This pilot study recruited active duty service members deployed to an area of combat operations. Enrollment was offered to service members scoring 50 or greater on the Zung Self-Rating Depression Scale. The authors implemented a systematic sampling technique randomly assigning the first subject and then alternating each subsequent subject to either a reference group which received the usual standard of care plus light therapy at 10,000 lux or a control group which received the usual standard of care and light therapy at 50 lux. Both groups received 90 min light sessions for five days.

SETTING

The study was conducted at Walter Reed Army Medical Center's Psychiatry Continuity Service.

MAIN OUTCOME MEASURE

Zung Self-Rating Depression Scale collected at baseline, after five consecutive daily light sessions, and one week later.

RESULTS

A repeated measures analysis of variance (RM ANOVA) was conducted to examine the change in Zung Depression results which showed a significant main effect for time F(2, 21)=5.05, p<0.02, indicating that depression scores reduced over time for both participant groups. Post hoc comparisons (with Bonferroni correction) demonstrated that the post-treatment Zung score was significantly lower indicating less depression than the baseline Zung score (p<0.004) and there was a statistical trend (p<0.05) for depression scores to be reduced halfway through the study in the treatment group.

CONCLUSION

The post hoc analysis hints at the possibility of a reduction in depression during the active phase of light treatment.

A randomized, placebo-controlled trial of bright light and high-density negative air ions for treatment of Seasonal Affective Disorder

This study, conducted over the course of 5 years, assessed the antidepressant efficacy of two active treatments, bright white light and high-density negative ions, and the efficacy of two placebo treatments, dim red light and low-density negative ions, for Seasonal Affective Disorder (SAD). In a controlled laboratory setting, 73 women with SAD were exposed to one of the four treatment conditions over 12 consecutive days. Pretreatment expectation ratings did not significantly differ among the four treatment groups; however, expectation scores and treatment benefits were positively related. Over the course of treatment, subjects in all four groups showed significant score decreases on the Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorder Version-Self Rating (SIGH-SAD-SR) and on the Beck Depression Inventory (BDI). For raw scale scores, neither main effects of treatment nor interactions between treatment and time were significant. When remission outcome criteria were used, bright white light was significantly more effective than any of the other three treatments, and exposure to high-density negative ions was more effective than either of the two placebo conditions, although the difference was not significant.

Exposure to bright light is associated with positive social interaction and good mood over short time periods: A naturalistic study in mildly seasonal people

Bright light is used to treat winter depression and might also have positive effects on mood in some healthy individuals. We examined possible links between bright light exposure and social interaction using naturalistic data. For 20 days in winter and/or summer, 48 mildly seasonal healthy individuals wore a light meter at the wrist and recorded in real-time their behaviours, mood, and perceptions of others during social interactions. Possible short-term effects of bright light were examined using the number of minutes, within any given morning, afternoon or evening, that people were exposed to light exceeding 1000 lux (average: 19.6min). Social interactions were labelled as having occurred under conditions of no, low or high bright light exposure. Independent of season, day, time, and location, participants reported less quarrelsome behaviours, more agreeable behaviours and better mood when exposed to high but not low levels of bright light. Given that the effects were seen only when exposure levels were above average, a minimum level of bright light may be necessary for its positive effects to occur. Daily exposure levels were generally low in both winter and summer. Spending more time outdoors and improving indoor lighting may help optimize everyday social behaviour and mood across seasons in people with mild seasonality.

Bright light exposure during acute tryptophan depletion prevents a lowering of mood in mildly seasonal women

We investigated the influence of bright light exposure on the mood-lowering effect of acute tryptophan depletion (ATD). Mildly seasonal healthy young women without a personal or family history of psychiatric disorders remained in either dim or bright light during two test days. Tryptophan-deficient and nutritionally balanced amino acid mixtures were administered in counterbalanced order. Mood state was assessed using the Profile of Mood States (POMS) and Visual Analogue Scales (VAS). In dim light, ATD decreased POMS scores across most subscales, indicating a worsening of mood. In bright light, mood was unaffected by ATD. Thus, bright light blocked the worsening of mood caused by ATD. This was also observed on the positive mood VAS. These results indicate a direct, immediate interaction between bright light and serotonin function. Bright light might help protect against ATD-induced mood change by increasing serotonin above the threshold level below which there is a lowering of mood.

Light exposure is related to social and emotional functioning and to quality of life in older women

While there are data supporting the use of light in clinical populations, there has been less investigation of relationships among light and psychological variables in non-clinical samples. Subjects were 459 ethnically diverse women (mean age 67.68) recruited as part of the Women's Health Initiative. Light exposure and sleep were measured with an Actillume wrist actigraph. Subjects completed questionnaires, investigating Social Support, Social Functioning, Social Strain, Quality of Life, Satisfaction with Life, Emotional Well-being, Optimism, Negative Emotional Expressiveness, and Role Limitation Due to Emotional Problems. Significant partial correlations (controlling for age, education and ethnicity) were found between mesor light exposure and Social Functioning, Quality of Life, Satisfaction with Life, and Emotional Well-Being. Quality of Life and Satisfaction with Life were also found to be significantly correlated with morning light. The most parsimonious model to account for the variance shared between mesor light and the predictors included only Quality of Life. The variance shared between mesor light exposure and social and emotional functioning could be subsumed under the variance shared between mesor light exposure and Quality of Life. Increased light exposure is related to improved quality of life and social and emotional functioning.

A placebo-controlled study of sertraline in the treatment of outpatients with seasonal affective disorder

RATIONALE

Seasonal affective disorder (SAD) is a relatively common cyclical depressive illness characterized by seasonal depressions during winter. The disorder is commonly responsive to light therapy, but antidepressant drug efficacy has not been definitely established. Serotonin selective re-uptake inhibitors are potentially efficacious treatments for SAD.

OBJECTIVES

The objective of this study was to evaluate the efficacy, tolerability and safety of sertraline treatment for SAD.

METHODS

One hundred and eighty seven outpatients with seasonal pattern recurrent winter depression (DSM-III-R defined) and a minimum 29-item Hamilton depression scale (SIGH-SAD version) score of 22 were randomized to 8 weeks treatment with either sertraline or placebo in a double-blind, multi-country, multi-center, parallel-group, flexible dose (50-200 mg once daily) study. Efficacy was investigated using physician and patient-rated scales measuring depression, anxiety and symptoms characteristic of seasonal affective disorder.

RESULTS

Sertraline produced a significantly greater response than placebo at endpoint as measured by changes in the 29-item and 21-item Hamilton depression scales, the clinical global impression (CGI) severity scale, the Hamilton anxiety scale, and the hospital anxiety and depression scale. The proportion of sertraline-treated subjects achieving a response on the CGI improvement rating (ratings of 1 or 2) at endpoint (last observation carried forward) was significantly greater than that of the placebo group. Overall sertraline was well tolerated with the most frequent placebo adjusted adverse events, being nausea, diarrhea, insomnia and dry mouth. Adverse events were mostly mild to moderate and transient.

CONCLUSIONS

Sertraline pharmacotherapy has been demonstrated to be an effective and well-tolerated therapy for out patients with SAD. As such, sertraline offers an important pharmacological option in the clinical management of this condition.

Light therapy for non-seasonal depression

BACKGROUND

Efficacy of light therapy for non-seasonal depression has been studied without any consensus on its efficacy.

OBJECTIVES

To evaluate clinical effects of bright light therapy in comparison to the inactive placebo treatment for non-seasonal depression.

SEARCH STRATEGY

We searched the Depression Anxiety & Neurosis Controlled Trials register (CCDANCTR January 2003), comprising the results of searches of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 -), EMBASE (1980 -), CINAHL (1982 -), LILACS (1982 -), National Research Register, PsycINFO/PsycLIT (1974 -), PSYNDEX (1977 -), and SIGLE (1982 - ) using the group search strategy and the following terms: #30 = phototherapy or ("light therapy" or light-therapy). We also sought trials from conference proceedings and references of included papers, and contacted the first author of each study as well as leading researchers in the field.

SELECTION CRITERIA

Randomized controlled trials comparing bright light with inactive placebo treatments for non-seasonal depression.

DATA COLLECTION AND ANALYSIS

Data were extracted and quality assessment was made independently by two reviewers. The authors were contacted to obtain additional information.

MAIN RESULTS

Twenty studies (49 reports) were included in the review. Most of the studies applied bright light as adjunctive treatment to drug therapy, sleep deprivation, or both. In general, the quality of reporting was poor, and many reviews did not report adverse effects systematically. The treatment response in the bright light group was better than in the control treatment group, but did not reach statistical significance. The result was mainly based on studies of less than 8 days of treatment. The response to bright light was significantly better than to control treatment in high-quality studies (standardized mean difference (SMD) -0.90, 95% confidence interval (CI) -1.50 to -0.31), in studies applying morning light treatment (SMD -0.38, CI -0.62 to -0.14), and in sleep deprivation responders (SMD -1.02, CI -1.60 to -0.45). Hypomania was more common in the bright light group compared to the control treatment group (risk ratio 4.91, CI 1.66 to 14.46, number needed to harm 8, CI 5 to 20). Twenty studies (49 reports) were included in the review. Most of the studies applied bright light as adjunctive treatment to drug therapy, sleep deprivation, or both. Treatment

REVIEWERS' CONCLUSIONS

For patients suffering from non-seasonal depression, bright light therapy offers modest though promising antidepressive efficacy, especially when administered during the first week of treatment, in the morning, and as an adjunctive treatment to sleep deprivation responders. Hypomania as a potential adverse effect needs to be considered. Due to limited data and heterogeneity of studies these results need to be interpreted with caution.

Seasonal affective disorder: an overview

Seasonal Affective Disorder (SAD) is a condition of regularly occurring depressions in winter with a remission the following spring or summer. In addition to depressed mood, the patients tend to experience increased appetite and an increased duration of sleep during the winter. SAD is a relatively common condition, affecting 1-3% of adults in temperate climates, and it is more prevalent in women. The pathological mechanisms underlying SAD are incompletely understood. Certain neurotransmitters have been implicated; a dysfunction in the serotonin system in particular has been demonstrated by a variety of approaches. The role of circadian rhythms in SAD needs to be clarified. The phase-delay hypothesis holds that SAD patients' circadian rhythms are delayed relative to the sleep/wake or rest/activity cycle. This hypothesis predicts that the symptoms of SAD will improve if the circadian rhythms can be phase-advanced. There is some experimental support for this. SAD can be treated successfully with light therapy. In classical light therapy, the SAD sufferer sits in front of a light box, exposed to 2000-10,000 lux for 30-120 min daily during the winter. Other forms of light treatments, pharmacotherapy, and other therapies are currently being tested for SAD.

Is there circannual variation of human platelet 5-HT(2A) binding in depression?

BACKGROUND

Seasonal variations in onset of mood disorders and in serotonergic function are reported, but their relationship is unclear.

METHODS

Circannual variation in platelet 5-HT(2A) binding was measured in 68 healthy subjects and 121 patients with a major depressive episode. In 73 patients the current episode began during Spring or Fall.

RESULTS

Significant, but different, circannual variations were found in patients compared with controls. Controls had two peaks of B(max), one in Spring and another in Fall. Fall and Winter K(D) was 41% lower compared with Spring and Summer K(D). Patients had a peak of B(max) in early Spring and a lesser one in late Fall. B(max) during Spring and Fall was 12% higher compared with Winter and Summer. K(D) was higher during October through February compared with the rest of the year. B(max) in patients was higher compared with controls in March. The opposite difference was observed in September-December. These differences from controls were mostly due to patients with an onset of the current major depressive episode during Spring or Fall.

CONCLUSIONS

Patients with a major depressive episode differed from controls in circannual variation of platelet 5-HT(2A) binding. This may reflect a vulnerability to seasonal effects in patients with mood disorders.

Seasonal affective disorder among general practice attenders

In this issue, Eagles et al report that people suffering from seasonal affective disorder (SAD) are heavy users of primary health care services (Eagles et al, 2002, this issue). Nearly 10% of patients attending practices in Aberdeen screened positive for SAD using the Seasonal Pattern Assessment Questionnaire (SPAQ; Rosenthal et al, 1987), among whom around half of those attending for interview fulfilled DSM–IV (American Psychiatric Association, 1994) criteria for recurrent major depression with seasonal pattern. The patients with SAD had consulted significantly more frequently over a 5-year period, with a variety of symptoms both related and unrelated to SAD, and had received significantly more prescriptions, investigations and referrals than patients found not to fulfil the criteria for SAD.

Is seasonal affective disorder a disorder of circadian rhythms?

Seasonal affective disorder (SAD) is a form of depression that starts in the fall and ends in the spring. This article reviews existing theories about the relationship between circadian rhythms and the disorder. Recent research indicates that as with pharmacologic antidepressants, at least 2-4 weeks are needed to demonstrate the effectiveness of bright-light therapy compared to placebo. The response to such treatment is strongest with precisely timed light exposure: treatment is optimal during the morning hours when the circadian system is susceptible to phase advance. Such clinical improvement is correlated with the magnitude of the phase shift induced. These observations suggest a model of circadian function in SAD and provide important guidelines for its treatment.

Sleep deprivation as a predictor of response to light therapy in major depression

BACKGROUND

While the majority of depressed patients benefit from total sleep deprivation (TSD), light therapy is regarded as a first-line treatment only for seasonal affective disorder (SAD). The results of light therapy in nonseasonal major depressive disorder have been non-conclusive. We examined the correlation of TSD response and light therapy response in major depressed patients.

METHODS

40 inpatients with major depressive disorder (seven with seasonal pattern, 33 without seasonal pattern) were deprived of a night's sleep. The TSD responders, as well as the TSD nonresponders, were randomly assigned to receive adjunct light therapy either with bright white light (2500 lux) or dim red light (50 lux) during 2 weeks beginning on the third day after TSD.

RESULTS

The 20 TSD responders improved significantly better under the light therapy than the 20 TSD nonresponders (according to the Hamilton Depression Rating Scale and the self-rating depression scale Bf-S; v. Zerssen).

LIMITATIONS

No significant difference could be found between the two light intensities. Since the patients were additionally treated with medication an interaction with the two adjunctive therapies cannot be excluded.

CONCLUSION

Our results indicate that a positive TSD response in major depressed patients can be predicative of beneficial outcome of subsequent light therapy.

Seasonality, social zeitgebers and mood variability in entrainment of mood. Implications for seasonal affective disorder

BACKGROUND

Seasonal variations in mood (seasonality) appear to be entrained to light, a physical zeitgeber. We hypothesised that people high in seasonality may be responsive to a range of zeitgebers, because of greater mood variability. We investigated whether the moods of people high in seasonality were more strongly entrained to the calendar week, a social zeitgeber, and whether any such effect was dependent on variability of mood.

METHODS

53 participants (14 male, 39 female; overall mean age=30) completed a daily mood report, over 56 consecutive days. Participants also completed the Seasonality Score Index (SSI) of the Seasonal Pattern Assessment Questionnaire. Each participant's time series of daily mood was analysed by spectral analysis to quantify the strength of their weekly mood cycle.

RESULTS

Participants with high SSI scores (> or =11) had significantly stronger weekly mood cycles than those with low SSI scores (<11), and significantly greater variability in mood. Covarying for mood variability reduced the difference between high and low SSI groups in mean strength of weekly mood cycle to non-significance.

LIMITATIONS

The time series of moods obtained was relatively short, and moods among high seasonal participants may have been affected by seasonal weather variability.

CONCLUSIONS

People high in seasonality appear to be more responsive to external zeitgebers, and this could be linked to their greater variability in mood. The integration of research on mood variability with research on SAD appears to be warranted.

Seasonal affective disorder: its recognition and treatment

This article provides an introduction to seasonal affective disorder (SAD) and outlines various therapies, including phototherapy (light therapy), used in its treatment. SAD, colloquially termed 'winter blues', is a common condition that is thought to be caused by reduced levels of daylight in winter. During this period sufferers generally feel low and may experience clinical depression. The Department of Psychiatry at the University of Southampton has an established SAD service as part of its mood disorders clinic, which was developed from a research-based clinical investigation unit set up in the early 1990s. SAD is described as a mood disorder with a seasonal pattern and has a greater prevalence in countries with greater northern latitude. The aetiology of SAD is unclear, although the most promising theory suggests the role of the neurotransmitter serotonin. SAD is difficult to treat with conventional antidepressants although there is evidence that serotonin selective reuptake inhibitors may be useful for some patients. Phototherapy (light therapy) has been used successfully by many patients although it remains controversial and difficult to obtain on the NHS.

A controlled study of light therapy in women with late luteal phase dysphoric disorder

Previous studies suggest that light therapy, as used to treat seasonal affective disorder, may be beneficial for pre-menstrual depressive disorders. We conducted a six-menstrual cycle randomized, double-blind, counter-balanced, crossover study of dim vs. bright light therapy in women with late luteal phase dysphoric disorder (LLPDD). Fourteen women who met DSM-III-R criteria for LLPDD completed two menstrual cycles of prospective baseline monitoring of pre-menstrual symptoms, followed by two cycles of each treatment. During the 2-week luteal phase of each treatment cycle, patients were randomized to receive 30 min of evening light therapy using: (1) 10000 lx cool-white fluorescent light (active condition); or (2) 500 lx red fluorescent light (placebo condition), administered by a light box at their homes. After two menstrual cycles of treatment, patients were immediately crossed over to the other condition for another two cycles. Outcome measures were assessed at the mid-follicular and luteal phases of each cycle. Results showed that the active bright white light condition significantly reduced depression and pre-menstrual tension scores during the symptomatic luteal phase, compared to baseline, while the placebo dim red light condition did not. These results suggest that bright light therapy is an effective treatment for LLPDD.

The role of genetic factors in the etiology of seasonal affective disorder and seasonality

The study of the genetic basis of seasonal affective disorder (SAD), a condition where depressions in fall and winter alternate with nondepressed periods in the spring and summer, has recently received attention. The data on the genetics of seasonal affective disorders are of three types: 1. Familiality: Studies on the prevalence of psychiatric disorders among relatives of patients with SAD suggested a familial contribution to the development of SAD; 2. Heritability: A survey of a cohort of twins showed that genetic effects exert a global influence across a variety of behavioral traits and accounted for at least 29% of the variance in seasonality in men and women; 3. Molecular genetic research: two genetic variants related to serotonergic transmission, the 5-HTTLPR and the 5-HT2A-1438G/A gene promoter polymorphisms, are associated with SAD; the former but not the latter polymorphism is related to seasonality. Future research may clarify the role of different genes in the development of SAD.

A risk-benefit assessment of pharmacotherapies for clinical depression in children and adolescents

Child and adolescent major depressive disorders are common and recurrent disorders. The prevalence of major depressive disorders is estimated to be approximately 2% in children and 4 to 8% in adolescents. Major depressive disorders in children are frequently accompanied by other psychiatric disorders, poor psychosocial outcome and a high risk of suicide and substance abuse, indicating the need for effective treatment and prevention. The use of antidepressant medications as the first line of treatment for children and adolescents with mild to moderate major depressive disorders has been questioned. However, some subgroups of patients may benefit from initial treatment with antidepressants. These subgroups may include patients who are unwilling or unable to undergo psychotherapy, have not responded to at least 8 to 12 sessions of psychotherapy, have bipolar, atypical or severe depression or have recurrent depression. Currently, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the first medication choice because of their efficacy, benign adverse effect profile, ease of use and low risk of death following an overdose. Further research in continuation and maintenance treatments, treatment of comorbid conditions, subtypes of depression, e.g. bipolar, atypical, seasonal, and combinations of pharmacotherapy and psychotherapy are needed. In addition, studies of the pharmacokinetics, pharmacodynamics and long term adverse effects of antidepressant medications in children and adolescents are warranted.

Women's mental health in primary care. Depression, anxiety, somatization, eating disorders, and substance abuse

Primary care physicians can improve the care of women patients by applying new concepts of women's physiology and psychosocial development. New developmental models that emphasize the importance of relationships in women's self-concept and well-being have led to effective psychotherapies for depression, eating disorders, anxiety and substance abuse. Many of these therapies can be offered in brief formats suitable to primary care settings. New biological treatments including the use of estrogen, thyroid hormone and bright light for depression and refeeding to increase metabolic rate in eating disorders also promise to expand the range of mental health problems that generalist physicians can treat successfully.

Atypical depressive symptoms in seasonal and non-seasonal mood disorders

The authors examined the rates of atypical depression and prevalence of specific atypical symptoms in patients with seasonal versus non-seasonal depression. Fifty-three patients with seasonal affective disorder (SAD) were compared to 54 patients with non-seasonal major depressive disorder (MDD) using the atypical depression diagnostic scale (ADDS). SAD patients scored significantly higher than non-seasonal MDD patients in hyperphagia and hypersomnia, and significantly lower in interpersonal sensitivity and other rejection avoidance. There was no difference in the rate of ADDS diagnosis of atypical depression. Differences between atypical depression and SAD suggest that they are separate subtypes of depression with an overlapping symptom picture.

L-tryptophan augmentation of light therapy in patients with seasonal affective disorder

OBJECTIVE

Up to one-third of patients with seasonal affective disorder (SAD) do not have a full response to light therapy. Given the evidence for serotonergic dysregulation in SAD, we examined the possible role of l-tryptophan as an augmentation strategy for nonresponders and partial responders to light therapy.

METHOD

Eligible drug-free patients meeting DSM-IV criteria for SAD were treated for 2 weeks using a standard morning light therapy regimen (10,000 lux cool-white fluorescent light for 30 minutes). Partial and nonresponders were treated for 2 weeks with open-label l-tryptophan (1 g 3 times daily) while light therapy was continued. Ratings at baseline and follow-up included the 29-item Structured Interview Guide for the Hamilton Depression Rating Scale, SAD version (SIGH-SAD) and the Clinical Global Impression (CGI) scale.

RESULTS

Sixteen patients began the l-tryptophan augmentation phase. Two patients discontinued medications within 3 days because of side effects. In the 14 patients completing treatment, the addition of l-tryptophan resulted in significant reduction of mean depression scores. Nine of 14 patients (64%) showed very good clinical responses to combined treatment and minimal side effects.

CONCLUSION

This open-label study suggests that l-tryptophan may be an effective augmentation strategy for those patients with SAD who show limited or poor response to bright ligh therapy. Further placebo-controlled studies are warranted to demonstrate efficacy.