Letters to the Editor
Treatment Option for Seasonal Affective Disorder
The following presentation revisits the diagnosis and successful treatment of major depressive disorder (MDE) with seasonal pattern.
Mr KC, a 29-year-old African-American married man, has a 6-year history of apathy, low energy, anhedonia, sadness, hopelessness, insomnia, and increase in joint pain, leading to impairment in his performance of military duties, as well as in his relationship with his wife. Onset of symptoms occurred yearly, beginning in the fall and remitting in the spring. A detailed history revealed no symptoms of mania, psychosis, or anxiety. He has no history of alcohol and drug use. A family history revealed a biological mother suffering from major depression and a biological father suffering with alcoholism. Other than knee-joint pain, the patient has good physical health. He has been employed with the military for over 10 years. He presented to his physician at a military base with these symptoms and was diagnosed with major depression with seasonal pattern. Phototherapy treatment was unavailable at the military base. Further, because of duty shifts, it could not be offered as an option. A review of antidepressants provided evidence of a trial of selective serotonin reuptake inhibitors (SSRIs). Thus, a trial of citalopram 20 mg daily was initiated. At 2 and 4 weeks follow-up, Mr KC reported an increase in his energy level, an upbeat feeling, an improvement in mood, a restoration of normal sleep, and a significant decrease in knee-joint pain. His wife provided collateral information confirming this improvement. He started using less nonsteroidal antiinflammatory drug (NSAID) medication for pain and could return to some athletic activities, which he could not tolerate earlier.
The DSM-IV states that the regular temporal relation between the onset of major depression in fall or winter and its full remission in spring characterizes seasonal patterns. In Alaska, a study estimated a prevalence of 9.2% for seasonal affective disorder (SAD) (1). Light therapy has been the treatment of choice, with minimal side effects. Headache, eyestrain, and harmful effects on the retina are, however, potential side effects (2). Data for the pharmacologic treatment of SAD are rather limited. In controlled trials, however, fluoxetine and propranolol have been effective. Open trials have also shown positive results with bupropion and monoamine oxidase inhibitors (3,4). One National Institute of Mental Health group has studied response to the serotonergic agent, m-cpp, in SAD patients, suggesting that serotonin dysregulation is an area for further study. One case study suggested that citalopram, an SSRI, was as effective as phototherapy for SAD. Because the neurobiology and the diagnostic validity of SAD is not always obvious, good history taking and a trial of antidepressants, such as citalopram, may prove to be an effective treatment option alone (5,6).
One major question that remains to be studied is whether patients with SAD should be weaned off antidepressants in the spring. If successful weaning off occurs, the same antidepressant medication may be as effective for the next likely episode.
1. Wehr TA, Rosenthal NE. Seasonality and affective illness. Am J Psychiatry 1989;146:829–39.
2. Tam EM, Lam RW, Levitte AJ. Treatment of seasonal affective disorder: a review. Can J Psychiatry 1995;40:457–66.
3. Partonen T, Lonnqvist J. Moclodemide and Prozac in a treatment of SAD. J Affect Disord 1996;25:93–9.
4. Dilsaver SC, Etal. Efficacy of bupropion in winter depression: an open trial. J Clin Psychiatry 1992;53:252–5.
5. Joseph-Vanderpol J R, and others. Seasonal variation in behavior responses to m-cpp in patients with SAD and controls. Biol Psychiatry 1993;33:496–504.
6. Wirz-Justice Etal. Comparison of light treatment with citalopram in winter depression. Int Clin Psychopharmacol 1992;7:109–16.
VK Dewan, MD, FRCPC
James L Sullivan, MD
Isha Dewan, Science Student