What can be added to an antidepressant (e.g. 200mg) for seasonal depression?

Treatment Augmentation for Seasonal Affective Disorder

For seasonal affective disorder inadequately responsive to antidepressant monotherapy (200mg), add bright light therapy as first-line augmentation, as this is the most evidence-based intervention specifically for SAD. 1

Primary Augmentation Strategy: Light Therapy

Light therapy is the most established augmentation for seasonal depression and should be implemented before considering other options:

• Bright light exposure has demonstrated antidepressant and energizing effects specifically in patients with seasonal affective disorder 2
• Light therapy is effective even in subsyndromal SAD (S-SAD), suggesting robust efficacy across the severity spectrum 2
• This intervention directly addresses the pathophysiology of SAD related to insufficient sunlight exposure 3

Implementation Details

• Initiate light therapy in autumn prior to onset of depressive symptoms 1
• Continue treatment through winter season 1
• Light therapy can be used concurrently with antidepressant medication without safety concerns 4

Common pitfall: Light therapy side effects include eyestrain, nausea, and agitation, though these typically remit spontaneously. Patients with eye disease or those using photosensitizing medications require periodic ophthalmological monitoring 4

Secondary Augmentation Options

Bupropion Addition or Switch

If the current antidepressant at 200mg is an SSRI and response remains inadequate:

• Bupropion is FDA-approved specifically for prevention of seasonal major depressive episodes in SAD 1
• Dosing: Start 150mg once daily, increase to 300mg once daily after 7 days 1
• Bupropion is activating and may provide rapid improvement in energy levels, a key symptom in SAD 4
• Contraindication: Do not use in patients with seizure disorders or agitated depression 4

Vitamin D Supplementation

While evidence is inconsistent, vitamin D may be considered as adjunctive therapy:

• Low 25-hydroxyvitamin D levels are associated with SAD and poor mental well-being 5, 3
• However, a randomized controlled trial of 70 μg daily vitamin D showed no significant improvement in SAD symptoms compared to placebo 6
• Despite mixed evidence, vitamin D supplementation shows overall favorable effects on depression prevention and may be worth trial given safety profile 5

Monitoring Requirements

Critical safety consideration: All patients on antidepressants require close monitoring for worsening depression and emergence of suicidal thoughts, particularly during the first 1-2 weeks after any treatment modification 4, 1

• Assess patient status within 1-2 weeks of adding augmentation therapy 4
• Monitor for agitation, irritability, or unusual behavioral changes indicating worsening depression 4
• Risk for suicide attempts is greatest during first 1-2 months of treatment changes 4

Treatment Duration and Discontinuation

• Continue combined treatment through winter season, then taper in early spring 1
• For patients on 300mg bupropion, decrease to 150mg once daily before discontinuing 1
• Timing of discontinuation should be individualized based on patient's historical pattern of seasonal episodes 1

If Augmentation Fails

If inadequate response persists after 6-8 weeks of augmentation:

• Consider switching to a different antidepressant class rather than continuing ineffective therapy 4
• Sertraline has demonstrated efficacy specifically for SAD in placebo-controlled trials (50-200mg daily) 7
• Cognitive behavioral therapy can be added to pharmacotherapy for treatment-resistant cases 4