What are the recommended medications for treating Seasonal Affective Disorder (SAD)?

Medications for Seasonal Affective Disorder

Bupropion extended-release is the first-line medication for preventing seasonal affective disorder, started at 150 mg daily in autumn and increased to 300 mg daily after 7 days, continued through winter and tapered in early spring. 1

FDA-Approved Treatment

Bupropion hydrochloride extended-release (XL) is the only FDA-approved medication specifically indicated for prevention of seasonal major depressive episodes in patients with SAD. 1

Dosing Protocol

• Start 150 mg once daily in the morning 1
• After 7 days, increase to target dose of 300 mg once daily 1
• Initiate in autumn, prior to onset of depressive symptoms 1
• Continue through winter season 1
• Taper in early spring: reduce to 150 mg daily before discontinuing 1
• May be taken with or without food; swallow whole, do not crush 1

Alternative SSRI Options

While not FDA-approved for SAD specifically, SSRIs have demonstrated efficacy in treating seasonal affective disorder and represent reasonable alternatives when bupropion is contraindicated or not tolerated. 2, 3, 4

Sertraline

• Demonstrated significantly greater response than placebo in an 8-week randomized controlled trial of 187 SAD patients 2
• Dose: 50-200 mg once daily (flexible dosing) 2
• Most frequent adverse events: nausea, diarrhea, insomnia, dry mouth (mostly mild to moderate and transient) 2
• First-line SSRI option based on strongest clinical trial evidence 5

Fluoxetine

• Shown approximately equal efficacy to light therapy in two trials involving 136 participants 4
• Well-tolerated by patients 5
• First-line SSRI option alongside sertraline 5

Other SSRIs

• Escitalopram, duloxetine, and other SSRIs may be effective but lack robust SAD-specific trial data 5
• Recent Cochrane review concluded insufficient evidence to definitively support any specific SGA for SAD treatment 4

Critical Warnings

Suicidality Risk

All antidepressants carry a boxed warning for increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults; monitor closely for worsening depression and emergence of suicidal ideation, especially during initial treatment. 1

Seizure Risk with Bupropion

Increase bupropion dose gradually to minimize seizure risk; maximum single dose is 300 mg daily for extended-release formulation. 1

MAOI Interactions

Allow at least 14 days between discontinuation of an MAOI and initiation of bupropion, and vice versa, due to risk of hypertensive reactions. 1

Dosage Adjustments

Hepatic Impairment

• Moderate to severe (Child-Pugh 7-15): maximum 150 mg every other day 1
• Mild (Child-Pugh 5-6): consider reducing dose and/or frequency 1

Renal Impairment

Consider reducing dose and/or frequency in patients with GFR <90 mL/min 1

Treatment Duration

For prevention of seasonal episodes, treatment should span the entire at-risk period (typically autumn through winter), with timing individualized based on the patient's historical pattern of seasonal episodes. 1

For acute treatment of a current seasonal depressive episode, continue antidepressant for several months beyond symptom resolution, as with other forms of major depression. 1

Common Pitfalls

• Starting bupropion too late in the season: Initiate in autumn before symptoms emerge for preventive effect 1
• Abrupt discontinuation: Always taper bupropion from 300 mg to 150 mg before stopping 1
• Overlooking bipolar features: Thoroughly evaluate for bipolarity before initiating antidepressant monotherapy, as SAD can occur in bipolar disorder 5
• Inadequate trial duration: Allow 8 weeks minimum to assess antidepressant efficacy 1

Evidence Limitations

The evidence base for SGAs in SAD remains limited, with only three small RCTs (total 204 participants) demonstrating very low to low certainty of evidence. 4 Despite this, bupropion's FDA approval for SAD prevention and clinical experience with SSRIs support their use as first-line pharmacological options. 1, 5