Seasonal affective disorder in children and adolescents

Bright Light Therapy for Major Depressive Disorder in Adolescent Outpatients: A Preliminary Study

BACKGROUND

Bright light therapy (BLT) has not been well-studied in adolescents with major depressive disorder, particularly in outpatient settings.

METHODS

We conducted an 8-week clinical trial of BLT in adolescents recruited from a primary care practice with moderate to severe major depression. Acceptability and feasibility were defined by daily use of the light box and integration into daily routines. To assess treatment effects, we utilized the Short Mood and Feelings Questionnaire (SMFQ) and actigraphic sleep variables.

RESULTS

Of the nine enrolled adolescents, the rate of daily use of the light therapy box was 100% at week 2, 78% at week 4 (n = 7), and 67% at weeks 6 and 8 (n = 6). Participants were better able to integrate midday BLT compared to morning BLT into their day-to-day routines. Mean depression scores improved during the 2-week placebo lead-in (dim red light-DRL) and continued to show significant improvement through 6 weeks of BLT. Sleep efficiency increased significantly (p = 0.046), and sleep onset latency showed a trend toward a significant decrease (p = 0.075) in the BLT phase compared to the DRL phase.

CONCLUSION

Bright light treatment that was self-administered at home was feasible, acceptable, and effective for adolescent outpatients with depression. Findings support the development of larger, well-powered, controlled clinical trials of BLT in coordination with primary care.

Light Therapy for Adolescent Depression: A Scoping Review

PURPOSE

Depressive disorders in adolescents are a major health concern associated with developmental, social, and educational impairment. Bright Light Therapy (BLT) is a feasible and effective treatment for depressive disorders in adults, but few controlled trials have been conducted with children or adolescents. This scoping review focuses on the current state of knowledge for BLT in the treatment of adolescent depression. We reviewed the literature for novel data and methodologic approaches using BLT and pediatric and young adult populations.

RECENT FINDINGS

BLT is a tolerable treatment with few side effects. However, there is a marked lack of well-powered studies to support BLT as a treatment for depressive disorders in adolescent populations. Given evidence of tolerability and positive treatment effect on depression in the adult literature, research is needed to establish the efficacy, feasibility, and acceptability of BLT in adolescents.

Tracking Mental Wellbeing of Dutch Adolescents During the First Year of the COVID-19 Lockdown: A Longitudinal Study

PURPOSE

Adolescents might be susceptible to the effects of the COVID-19 lockdown. We assessed changes in mental wellbeing throughout the first year of the pandemic and compared these with prepandemic levels.

METHODS

This five-wave prospective study among Dutch adolescents aged 12-17 years used data collected before the pandemic (n = 224) (T0), in May (T1), July (T2), and October 2020 (T3), and in February 2021 (T4). Generalized estimating equations were used to assess the association between stringency of the lockdown with mental wellbeing.

RESULTS

Adolescents had a lower life satisfaction during the first full lockdown (T1) [adjusted β: -0.36, 95% confidence interval (CI): -0.58 to -0.13], during the partial lockdown (T3) (adjusted β: -0.37, 95% CI: -0.63 to -0.12), and during the second full lockdown (T4) (adjusted β: -0.79, 95% CI: -1.07 to -0.52) compared to before the pandemic (T0). Adolescents reported more internalizing symptoms during only the second full lockdown (T4) (adjusted β: 2.58, 95% CI: 0.41-4.75). During the pandemic [at T1 (adjusted β: 0.29, 95% CI: 0.20-0.38), T2 (adjusted β: 0.36, 95% CI: 0.26-0.46), T3 (adjusted β: 0.33, 95% CI: 0.22-0.45), and T4 (adjusted β: 0.20, 95% CI: 0.07-0.34)], adolescents reported a better psychosomatic health, partly attributable to less trouble falling asleep (p < .01).

DISCUSSION

The COVID-19 lockdown measures have had both a negative and positive impact on mental wellbeing of Dutch adolescents. However, mental wellbeing was most impacted during the second full lockdown compared to before the pandemic.

Seasonal variation in specific depressive symptoms: A population based study

INTRODUCTION

Depression varies with season in Canadian youth. However, the symptom profile of seasonal depression may differ from that of non-seasonal depression. Here we evaluate which specific symptoms vary by season.

METHODS

Using data from the 2015/2016 Canadian Community Health Survey, cross-sectional analysis was conducted. The Patient Health Questionnaire-9 (PHQ-9) was administered to respondents in 8 provinces/territories (n ≈ 53,000), with interviews conducted throughout the year. Seasonal effects were assessed using quadratic terms in a logistic regression model. Guided by previous literature and analysis, analyses were stratified by age into youth (age 12-24) and adult (age 25+) groups.

RESULTS

In the youth, 8 items of the PHQ-9 exhibited a significant season variation: lack of interest/pleasure, feeling depressed/down, hypersomnia/insomnia, lacking energy, poor appetite/overeating, feeling bad about yourself/ like a failure, being slow/fidgety, and trouble concentrating. In the adult group, only sleep and poor appetite/overeating exhibited a seasonal effect. Notably, symptoms of self-harm/suicide did not demonstrate seasonality in either group.

LIMITATIONS

Due to use of cross-sectional data and a brief symptom rating scale, conventional criteria for Seasonal Affective Disorder or Major Depressive Disorder with seasonal variation could not be applied. Also, treatment status of respondents was not assessed in the survey, therefore possible confounding by this variable could not be assessed.

CONCLUSIONS

A seasonal pattern was observed in most symptoms of depression in Canadian youth, whereas in adults, only symptoms related to sleep and appetite disturbance displayed seasonal variation.

Seasonal affective disorder, winter type: current insights and treatment options

Seasonal affective disorder (SAD), winter type, is a seasonal pattern of recurrent major depressive episodes most commonly occurring in autumn or winter and remitting in spring/summer. The syndrome has been well-known for more than three decades, with light treatment being the treatment of first choice. In this paper, an overview is presented of the present insights in SAD. Description of the syndrome, etiology, and treatment options are mentioned. Apart from light treatment, medication and psychotherapy are other treatment options. The predictable, repetitive nature of the syndrome makes it possible to discuss preventive treatment options. Furthermore, critical views on the concept of SAD as a distinct diagnosis are discussed.

[Sexual dysfunction in men with depressive disorders]

In this article, the authors summarize literature data about sexual dysfunction in depression in men. Prevalence, clinical issues and pathogenesis of sexual dysfunction in patients with affective disorders are described. The incidence of depression is steadily growing, and the structure of depressive disorders is becoming more complicated. Comorbid sexual disturbances continued to be one of not enough developed aspects of depressive disorders.

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.

Winter Depression: Integrating mood, circadian rhythms, and the sleep/wake and light/dark cycles into a bio-psycho-social-environmental model

The phase shift hypothesis (PSH) states that most patients with SAD become depressed in the winter because of a delay in circadian rhythms with respect to the sleep/wake cycle: According to the PSH, these patients should preferentially respond to the antidepressant effects of bright light exposure when it is scheduled in the morning so as to provide a corrective phase advance and restore optimum alignment between the circadian rhythms tightly coupled to the endogenous circadian pacemaker and those rhythms that are related to the sleep/wake cycle. Recent support for the PSH has come from studies in which symptom severity was shown to correlate with the degree of circadian misalignment: it appears that a subgroup of patients are phase advanced, not phase delayed; however, the phase-delayed type is predominant in SAD and perhaps in other disorders as well, such as non-seasonal unipolar depression. It is expected that during the next few years the PSH will be tested in these and other conditions, particularly since healthy subjects appear to have more severe symptoms of sub-clinical dysphoria correlating with phase-delayed circadian misalignment; critically important will be the undertaking of treatment trials to investigate the therapeutic efficacy of morning bright light or afternoon/evening low-dose melatonin in these disorders in which symptoms are more severe as the dim light melatonin onset (DLMO) is delayed with respect to the sleep/wake cycle (non-restorative sleep should also be evaluated, as well as bipolar disorder). The possibility that some individuals (and disorders) will be of the phase-advanced type should be considered, taking into account that the correct timing of phase-resetting agents for them will be bright light scheduled in the evening and/or low-dose melatonin taken in the morning. While sleep researchers and clinicians are accustomed to phase-typing patients with circadian-rhythm sleep disorders according to the timing of sleep, phase typing based on the DLMO with respect to the sleep/wake cycle may lead to quite different recommendations for the optimal scheduling of phase-resetting agents, particularly for the above disorders and conditions.

High prevalence of self-reported depressive mood during the winter season among Swedish senior high school students

OBJECTIVE

There are few studies regarding the prevalence of seasonal variation in mood among children and adolescents. The main objective of this study was to estimate the prevalence of self-reported depressive mood during the winter season among Swedish adolescents and to investigate gender differences. Another aim was to analyze the factor structure and internal consistency of the Kiddie SPAQ (K-SPAQ), a pediatric version of the Seasonal Pattern Questionnaire (SPAQ).

METHOD

All students 17 to 18 years old, registered in the second year of senior high school in Falun, a district in central Sweden, were screened with the K-SPAQ in January 2003 (response rate 87.3%, n = 756).

RESULTS

The prevalence of self-reported depressive mood during the winter season was estimated at 20.1% (n = 151/751) and was higher among girls (25.5%) than boys (13.8%). Approximately 8% reported more severe depressive symptoms. Depressive mood during the summer was rare (0.1%, n = 1/751). Factor analysis of the General Seasonal Score items in the K-SPAQ revealed a two-factor structure. A Cronbach's alpha of 0.87 demonstrated a good internal consistency.

CONCLUSIONS

Depressive symptoms during autumn and winter were common among Swedish senior high school students, especially among girls. This is probably an underdiagnosed condition among adolescents that ought to receive more attention from the health and school authorities.

Update on the biology of seasonal affective disorder

The etiology and pathophysiology of seasonal affective disorder (SAD) has been linked to the seasons and to light since its first conceptualization. Aspects of SAD that make it particularly amenable to biological investigation include the predictable recurrent episodes, the rapid response to a nonpharmacologic treatment, the specific neurovegetative features, and the availability of rich animal models of seasonality. This paper reviews new findings for the major biological hypotheses for SAD, focusing on circadian rhythms, neurotransmitters, and molecular genetics. Integrative issues and future directions for the study of SAD, including the heuristic value of a dual-vulnerability hypothesis that conceptualizes seasonality as a dimensional construct and the importance of studying endophenotypes, will be discussed.

A help-line for children. Seasonal variations in issues

The objectives of the study were to describe monthly variations in issues in calls to a help-line for children and adolescents. All 80,983 calls to a Red Cross Help-Line for children in 1991-1997 were included. In 22,698 calls, information about age, sex or issue could be identified. A monthly variation in frequency of calls with peaks in April and November and a correlation with the absolute values of monthly changes in length of day were found. Conversations concerning psychiatric suffering were more frequent in January or February and less frequent than expected in May/June and December. Conversations about sexuality correlated with the frequencies of births in the adult population 9 months later. A spring and fall peak in total calling and a winter peak in calls for depression, anxiety, pain and neglect were described.

Cross-regional survey of seasonal affective disorders in adults and high-school students in Japan

BACKGROUND

In Asian countries, there is no epidemiological report on seasonal affective disorder (SAD) in different age groups and different geographic regions surveyed at the same time. The aim of this study was to estimate the prevalence rates of SAD and risk factors for SAD in adults and high-school students, with special reference to the difference of winter SAD between northern and southern regions in Japan.

METHODS

A total of 3237 high-school students and 4858 workers living in Japan (31.3-43.5 degrees N) responded to this epidemiological survey using Japanese version of the Seasonal Pattern Assessment Questionnaire (SPAQ).

RESULTS

The overall prevalence rates of winter SAD (subsyndromal winter SAD) and summer SAD (subsyndromal summer SAD) in high-school students were 0.91(2.21) and 0.81(2.57)%, respectively. In workers, these rates were 0.45(1.16) and 0.43(0.71)%, respectively. Although no regional difference was noted in high-school students with winter seasonal type, the estimated odds ratio of this type for northern workers was nearly 3-fold higher than the southern counterparts. The prevalence rates of each seasonal type were not significantly different between two sexes in both age groups. No clear dependence on latitude was seen with regard to summer SAD in both age groups.

LIMITATIONS

The effect of climate on SAD could not be entirely excluded from geophysical factor as indexed by latitude.

CONCLUSIONS

SAD was less common in adults than in high-school students. While latitude was a major determinant of winter type in adults, socio-cultural factors or other contributing factors might affect the development of this type in high-school students.

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.

Seasonal variations in children's calls to a help-line: implications for preventive services

BACKGROUND

To investigate seasonal variations in telephone calls to a help-line for children, and their correlation to changes in length of day, latitude and age.

METHOD

691,787 calls to the Red Cross Help-Line in Norway for children in the three-year period 1996-1998 were included.

RESULTS

Monthly frequencies of calls deviated significantly from an expected even distribution (chi2=9446.34, df=11, P<0.0001). The frequency curve for calls peaked in April and October and had its lowest level in July and December. Variation was pronounced: the mean number of daily calls varied between 436 in July and 886 in April. There was a strong and positive correlation between the number of calls and the change in length of day across the year (r(s)=0.76, N=12, P<0.01). Increasing latitude correlated positively with the range of the monthly observed/expected ratios of calls (r(s)=0.79, N=7, P<0.05). The frequency of calls was largest among children 12 to 14 years of age. Age correlated negatively with the range of monthly observed/expected ratios of calls (r=-0.94, N=12, P<0.001).

LIMITATIONS

Social and cultural factors could not be explored in the design used in the present study.

CONCLUSIONS

The frequency of calls from children correlates positively with change in length of day (i.e., maximal in spring and fall), and the magnitude of the seasonal variation correlates positively with latitude and negatively with age. Knowledge of seasonal variation in requests for help may have value in planning services for children.

Day length associates with activity level in children living at 60 degrees north

The associations between day length and activity, rest-activity rhythm, and psychiatric symptoms were studied. Sixty-six healthy children participated in the study during one year. They were monitored for 72 consecutive hours with belt-worn activity monitors (actigraphs) to obtain objective data on their activity levels during the day and night. In addition, the parents filled out the Child Behavior Checklists. It was found, that the mean total and day and night time activity levels were increased and the relative circadian amplitude blunted with the longer day length. It was concluded that day length was associated with activity level and rest-activity rhythm and this association may reflect the seasonal changes in these parameters.

Seasonal mood patterns in a northeastern college sample

Given that seasonality can be conceptualized along a developmental continuum, it is surprising that the college population has been largely excluded from previous epidemiological research on Seasonal Affective Disorder (SAD). In this study, college students completed the Seasonal Pattern Assessment Questionnaire (SPAQ) and Beck Depression Inventory twice during either the Fall or Spring academic semester. SAD prevalence rates were similar to those of nearby adult samples. The SPAQ demonstrated high test-retest reliability when administered during different seasons; however, gender differences only emerged during winter SPAQ administrations.

Seasonal affective disorder and latitude: a review of the literature

BACKGROUND

The aim of the study is to investigate the relationship between the prevalence of SAD and latitude.

METHODS

An overview of the epidemiological literature on the prevalence of SAD is given and studies relevant for the latitudinal dependency of prevalence will be analyzed and discussed.

RESULTS

The mean prevalence of SAD is two times higher in North America compared to Europe. Over all prevalence studies, the correlation between prevalence and latitude was not significant. A significant positive correlation was found between prevalence and latitude in North America. For Europe there was a trend in the same direction.

CONCLUSIONS

The influence of latitude on prevalence seems to be small and other factors like climate, genetic vulnerability and social-cultural context can be expected to play a more important role. Additional controlled studies taking these factors into account are necessary to identify their influence.

Newer antidepressants. Beyond selective serotonin reuptake inhibitor antidepressants

This article outlines the use of alternative agents to TCAs and SSRIs. Features of the more commonly used alternative antidepressant agents are outlined. In addition, antidepressant agents that are currently either under development or used in other countries are indicated for completeness because it seems likely that many of these will be introduced in the United States within the next few years. Many of these agents will be used by pediatricians and child psychiatrists for treatment of depression in children, and although much further research is needed, the future for alternative antidepressants and augmenting strategies is extremely promising.

Case study: dawn simulation as maintenance treatment in a nine-year-old patient with seasonal affective disorder

After four winter seasons of successful treatment with light boxes, a 9-year-old patient with seasonal affective disorder refused to make further use of the light box. Instead he was treated with dawn simulation (a dim light administered just before waking up and gradually increased in intensity). The patient used dawn simulation therapy from October until mid-May, with an occasional variation of the maximum light intensity (100, 200, or 300 iux). The patient, his parents, and his teacher were all happy with this type of treatment.

Case series: pediatric seasonal affective disorder. A follow-up report

Six subjects who as children had received a diagnosis of seasonal affective disorder consented to participate in a 7-year follow-up study. Structured and semistructured interviews were conducted to assess the course of illness, response to treatment, and current clinical state. Seasonal patterns of symptoms and response to light therapy remained relatively stable over a 7-year period. Two subjects were using adjunctive fluoxetine. Seasonal affective disorder can occur in children and adolescents, responds to light therapy, and should be considered in the differential diagnosis of pediatric affective symptoms or cyclic school performance.

[Treatment of sleep disorders in children]

Sleep disorders require careful evaluation, precise diagnosis and a systematic search for a cause before considering treatment. Hypnotics must never be prescribed directly and when necessary it must be used precautionally during a short period of time, as little is known on their long term effects in children. In addition some psychotropic drugs may lead to tolerance and addiction. Educational and behavioural therapy together with sleep hygiene, have proven to be efficient in most situations. Awaking stimulants are indicated in primary hypersomnia.

A controlled trial of light therapy for the treatment of pediatric seasonal affective disorder

OBJECTIVE

To evaluate the efficacy of light therapy for the treatment of pediatric seasonal affective disorder (SAD).

METHOD

28 children (aged 7 to 17 years) at two geographically distinct sites were enrolled in a double-blind, placebo-controlled, crossover trial of bright-light treatment. Subjects initially entered a week-long baseline period during which they wore dark glasses for an hour a day. They were then randomly assigned to receive either active treatment (1 hour of bright-light therapy plus 2 hours of dawn simulation) or placebo (1 hour of clear goggles plus 5 minutes of low-intensity dawn simulation) for 1 week. The treatment phase was followed by a second dark-glasses phase lasting 1 to 2 weeks. After this phase, the children received the alternate treatment. Response was measured using the parent and child versions of the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders version (SIGH-SAD).

RESULTS

Data were analyzed as change from baseline. SIGH-SAD-P total depression scores were significantly decreased from baseline during light therapy compared with placebo (one-way analysis of variance, rho = .009), and no differences were found between the placebo and control phases. Subscores of atypical and typical depression were also significantly decreased during the active treatment (rho = .004 and .028, respectively). A similar trend was noted with the SIGH-SAD-C, but this did not reach significance. At the end of the study, 78% of the parents questioned and 80% of the children questioned rated light therapy as the phase during which the child "felt best."

CONCLUSION

Light therapy appears to be an effective treatment for pediatric SAD.

Circadian rest-activity disturbances in children with seasonal affective disorder

OBJECTIVE

Seasonal affective disorder (SAD) affects from 1.7% to 5.5% of children. Previous studies found that nonseasonally depressed children had a blunted circadian rhythm, while adults with SAD had a delayed and poorly entrained rhythm. The purpose of this study was to determine whether pediatric SAD more closely resembles nonseasonal pediatric depression or adult SAD.

METHOD

Twelve normal, healthy volunteers (11.6 +/- 3.7 years; 6 female, 6 male) and 14 unmedicated children with SAD (11.0 +/- 3.3 years; 9 female, 5 male) meeting Rosenthal/NIMH criteria for SAD and Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version criteria for major depression had their levels of activity recorded for 72 hours (weekdays) using belt-worn actigraphs.

RESULTS

The SAD group had blunted circadian amplitudes that were 10% lower than normal (p = .004). They were more poorly modeled by the standard cosinor equation (p = .001), and a circadian rhythm accounted for 39% less of the variability in their activity profile (p = .007). The amplitude of the 12-hour harmonic rhythm was markedly increased. There were no differences between SAD and control children in the timing of the circadian rhythm and degree of entrainment.

CONCLUSIONS

Children with SAD displayed dysregulated circadian activity rhythms comparable with those reported in nonseasonally depressed children, yet different from those observed in adults.

Current approaches to the psychopharmacologic treatment of depression in children and adolescents

TOPIC

A review of major depressive disorder and antidepressant drug treatment in children and adolescents.

PURPOSE

This paper provides a synthesis of current information regarding diagnosis, psychobiology, psychopharmacology, and practice guidelines for psychiatric nurses involved in the treatment of depression in children and adolescents.

SOURCES

Recent journal and book publications regarding the psychopharmacological treatment of depression in children and adolescents.

CONCLUSION

Although there is far less research to guide the psychopharmacological treatment of depression in children and adolescents than there is for adults, these treatments can be safely administered and effective for some individuals in this age group.

Rapid cycling in severely multidisabled children: a form of bipolar affective disorder?

A debilitating, regularly recurring, biphasic disorder is described in 6 severely multidisabled children. It was characterized by several days of lethargy, withdrawal, loss of abilities, irritability, and hypersomnolence followed or preceded by a high-energy state for several days during which the children slept very little, at times were euphoric, had improved mental ability, and were hyperactive. These cyclic episodes had been present for years but unexpectedly disappeared in one child. The etiology is unknown, in spite of detailed neurologic, metabolic, and endocrine investigations. All patients had family histories positive for affective disorder. Melatonin treatment helped to regulate the coexisting chronic sleep disorders of 3 children but failed to eliminate the cycles. Antiepileptic drug treatment, lithium, sedatives, stimulants, tranquilizers, and light therapy were largely ineffective. The children's symptoms and signs fit the diagnostic criteria of a bipolar affective illness, as it was modified for patients with associated neurologic disability; therefore, the patients appeared to have a unique disorder that closely resembles or is a variant of rapid cycling affective disorder.

Parental reports of seasonal mood and behavior changes in children

OBJECTIVE

The chief purpose of this study was to investigate the nature and prevalence of children's seasonal symptoms.

METHOD

Parental reports of seasonal changes in six mood or behavioral symptoms (sleeping, eating, irritability, energy, withdrawal, and sadness) were surveyed for children living across the United States. The sample included 892 girls (mean age = 10.5 +/- 1.0 years) and 788 boys (mean age = 10.6 +/- 0.9 years), with a response rate of 46% for girls' parents and 39% for boys' parents.

RESULTS

At least one winter recurring symptom was reported in 48.5% of children, as compared with 9.1% in fall and 10.8% in spring. Winter symptoms were reported equally in girls and boys with one exception ("is tired"); age effects were found for three symptoms only in girls ("sleep more," "is tired," and "withdraws"). Regional effects showed more winter symptoms reports in northern zones than in southern zones.

CONCLUSIONS

Given the potential therapeutic benefit of light therapy in children with such seasonal patterns, careful assessment of seasonality is merited for children with winter mood and behavior problems.

Clinical and biochemical aspects of depressive disorders: III. Treatment and controversies

The present document is the final of three parts of a review that focuses on recent data from clinical and animal research concerning the biochemical bases of depressive disorders, diagnosis, and treatment. Various treatments for depression, including psychotherapy, pharmacological, and somatic treatments, will be described in this third part. Also, some of the controversies in the field, as well as a summary of the most salient points of the review, will be discussed. Previous sections of this review dealt with the classification of depressive disorders and research techniques for studying the biochemical mechanisms of these disorders (Part I) and various transmitter/receptor theories of depressive disorder (Part II).

Seasonal affective disorder in adolescence

Two adolescent girls with seasonal affective disorder (SAD) are described. It is suggested that the classic symptom profile seen in adults is not characteristic in younger subjects. Although hypersomnia is prominent, increased appetite and carbohydrate craving are rarely reported. Local meteorological data link the course of the disorder in one case to the hours of sunshine and ambient temperature during the winter months.

Phototherapy of seasonal affective disorder in an adolescent female

Seasonal affective disorder and its response to phototherapy has not been extensively studied in children and adolescents. In this case study, a 16-year-old girl with a 3-year history of seasonal affective disorder sought treatment. An A-B-A'-B study design demonstrates the remission of symptoms with phototherapy.

Mood disorders. Is your primary care patient depressed?

Treatment of patients with mood disorder can be one of the most rewarding experiences in medicine. Optimal treatment is contingent on accurate diagnosis according to current criteria and terminology. Major depression needs further categorization in reference to atypical or psychotic features, seasonal aspects, melancholia, mania, or dysthymia. Most patients with major depression need pharmacotherapy, often in combination with psychotherapy. A number of therapeutic regimens using various antidepressant agents are available.

Seasonal affective disorder, the depression of winter: a literature review and description from a nursing perspective

This article presents a literature review and description of seasonal affective disorder (SAD). SAD is a newly recognized disorder, differentiated from other affective illnesses by its seasonality (with midwinter dysthymia and spring/summer remission), and its atypical symptoms of hypersomnia and hyperphagia. SAD symptoms remit with travel towards the equator or with bright light treatments, possibly indicating a chronobiological circadian etiology. This article introduces aspects of SAD that are amenable to the nursing process, including assessment of the seasonality of dysthymic symptoms; diagnoses of patient responses; referral, education, and psychotherapeutic interventions; and evaluation of patient responses to interventions. Since SAD is found predominantly in young women, and because symptoms may be exacerbated by rotating shifts, it is possible that nurses may have a higher incidence of SAD, compared with other professions.

Is winter depression a bipolar disorder?

Sixty-one winter depressive patients were evaluated for evidence of bipolar illness. Using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version and the General Behavior Inventory, only nine (15%) could be considered bipolar. On prospective evaluation of patients during the summer following winter depression, few showed signs of manic or hypomanic symptoms. Also, few patients had a family history of bipolar illness. When patients were asked to evaluate symptoms of winter depression, lack of energy was found to be the most prominent feature of the syndrome.

Constant exposure to darkness produces supersensitivity to nicotine

Treatment with full-spectrum bright artificial light produces subsensitivity to the hypothermic effect of nicotine in the rat. The authors hypothesized that prolonged exposure to darkness would produce the opposite effect. The thermic responsiveness of 11 rats to nicotine (base), 0.25 mg/kg IP, was telemetrically measured at baseline, after 7 days of exposure to constant darkness, and 2, 5, and 12 days after being returned to standard vivarium conditions. Exposure to constant darkness enhanced the hypothermic response to nicotine. The sample exhibited a hyperthermic response to nicotine 2 and 5 days after being returned to the standard vivarium conditions with a 12-hour-light/12-hour-dark cycle. The magnitude of the hyperthermia observed is characteristic of the response to the injection of saline. Twelve days after return to standard vivarium conditions the thermic response of the sample was at baseline.

Geophysical variables and behavior: LVII. Seasonal affective disorder and phototherapy

Seasonal affective disorder, depressive symptoms that recur in fall and winter and abate in spring-summer, for many patients in the United States and Europe, have been alleviated by exposure to bright, full spectrum light for several hours daily (phototherapy). The characteristics of these patients, the procedures used, the theoretical explanations of the mechanisms, and the potential of phototherapy are reviewed.

Phototherapy for depressive disorders: a review

The use of bright light (phototherapy) for psychiatric disorders has recently generated much interest among researchers and the lay population. The authors review the treatment studies of phototherapy for seasonal and non-seasonal depressive disorders, and the empirical evidence for theories of the psychophysiology of phototherapy. Although its mechanism of action remains to be explained, phototherapy appears to be a safe and effective treatment for seasonal depression and a promising treatment for non-seasonal depression. Further questions and future research directions are presented.

Bright artificial light produces subsensitivity to clonidine

The authors used a thermoregulation paradigm to test the hypothesis that chronic treatment with bright artificial light produces subsensitivity to the hypothermic effects of clonidine, an alpha 2-agonist. One week of treatment produced blunting of the hypothermic response to clonidine (p less than 0.00001). These findings are consistent with previous reports that somatic treatments for depression produce subsensitivity of the alpha 2-receptor.

Bright artificial light produces subsensitivity to nicotine

Bright artificial light is a treatment for seasonal depression. Eleven (11) rats were exposed to bright artificial light (11,500 lux) for two consecutive weeks. The thermic response to nicotine was measured prior to light exposure and after one and two weeks of treatment. The thermic response to nicotine at baseline was -1.69 +/- 0.25 degrees C (mean +/- SEM). The thermic response to nicotine was -0.66 +/- 0.12 degrees C (p less than 0.002) after one and +0.31 +/- 0.14 degrees C (p less than 0.000025) after two weeks of light exposure. The change in temperature was different between weeks one and two (p less than 0.000025). The exposure of animals to constant light at an intensity of 300 lux did not blunt the hypothermic response to nicotine. These findings suggest that bright artificial light, like other antidepressant treatments, produces subsensitivity of a nicotinic mechanism involved in the regulation of core temperature.

Bright artificial light subsensitizes a central muscarinic mechanism

Supersensitivity of a muscarinic mechanism is implicated in the pathophysiology of depression. Bright artificial light is efficacious in the treatment of Seasonal Affective Disorder (SAD). We studied the effect of constant bright light (11,500 lux) on the sensitivity of adult, male rats to oxotremorine, 1.5 mg/kg ip, using a repeated measures design. Oxotremorine challenges were proceeded by the injection of methylscopolamine, 1 mg/kg ip, by 30 minutes. Temperature was telemetrically measured every 10 minutes for 120 minutes starting 10 minutes after the injection of oxotremorine. Prior to and after 7 continuous days of exposure to bright light, the sample exhibited a hypothermic response of 2.50 +/- 0.48 degrees C (mean +/- SEM) and 0.29 +/- 0.31 degrees C (mean +/- SEM), respectively (p less than 0.0014). All 7 animals exhibited blunting to the thermic response to oxotremorine. Bright light also blocked the capacity of amitriptyline to supersensitize a central muscarinic mechanism. Exposure to light at an intensity of 300 lux for 7 days had no effect on the thermic response to oxotremorine. These data are consistent with the hypotheses that the biology of depression involves supersensitivity of central muscarinic mechanisms and that the effects of bright artificial light are not the consequence of shifting circadian rhythms.

Fluoxetine subsensitizes a nicotinic mechanism involved in the regulation of core temperature

Fluoxetine HCl, 10 mg/kg ip, twice daily produced subsensitivity to the hypothermic effects of nicotine (base), 1 mg/kg ip, after 1 (p less than 0.02) and 2 (p less than 0.002) weeks of treatment. Phenelzine sulfate, desipramine HCl and bright artificial light produced the same effect. The capacity of three chemically distinct classes of antidepressants and bright artificial light (a treatment for seasonal depression) to produce this result suggests that effects on nicotinic mechanisms may be involved in the mechanism of action of these treatments.

Seasonal affective disorder: a review of the syndrome and its public health implications

Seasonal affective disorder (SAD) is a disturbance of mood and behavior which resembles some seasonal changes seen in lower mammals. Like these animal seasonal changes, SAD is thought to be related to decreased sunlight during winter months. [SAD has been successfully treated with exposure to bright artificial light of higher intensity than is usually present in the home or workplace. Many people not suffering from SAD may nonetheless have seasonal changes which could be helped by environmental light supplementation. Lighting standards in the home and workplace should be re-evaluated on the basis of new knowledge of the psychobiological effects of light.] We review the literature on SAD and discuss its public health implications in the context of a typical case presentation.