What are the treatment options for a patient with Seasonal Affective Disorder?

Treatment Options for Seasonal Affective Disorder

Light therapy at 10,000 lux for 30 minutes each morning is the first-line treatment for Seasonal Affective Disorder, with bupropion extended-release as an effective pharmacologic alternative for prevention and treatment. 1, 2

First-Line Treatment: Light Therapy

Dosing and Administration

• Administer 10,000 lux for 30 minutes daily in the morning, or alternatively 2,500 lux for 2 hours daily if a lower-intensity device is used 1
• Morning administration is superior to evening treatment and should be the standard timing 1
• Treatment should be initiated in autumn, prior to the onset of depressive symptoms, and continued through the winter season 2
• Commercial light boxes are widely available and effective when used consistently at the same time each day 3

Expected Outcomes

• Light therapy demonstrates significant efficacy with a standardized mean difference of -0.37 compared to placebo for depression ratings 4
• Response rates are 42% higher with active light treatment compared to placebo 4
• Symptom improvement typically occurs within 2-4 weeks of consistent use 5, 6

Safety Profile and Monitoring

• Monitor closely for emergent hypomania, particularly in the first few days of treatment, as this is the most significant risk 1, 7
• Common side effects include eyestrain, nausea, and agitation, with most resolving spontaneously without intervention 1
• Patients with eye disease or those taking photosensitizing medications require periodic ophthalmologic and dermatologic monitoring 1
• Long-term use (up to 6 years) has shown no ophthalmologic changes in patients without preexisting conditions 8

Pharmacologic Treatment: Bupropion Extended-Release

Dosing for SAD Prevention

• Start with 150 mg once daily; after 7 days, increase to the target dose of 300 mg once daily in the morning 2
• Initiate in autumn prior to symptom onset and continue through winter season 2
• Taper to 150 mg once daily before discontinuing in early spring 2
• Bupropion appears to have the strongest evidence supporting long-term preventive use 3

Key Safety Considerations

• To minimize seizure risk, increase the dose gradually and do not exceed 300 mg/day for SAD 2
• Swallow tablets whole; do not crush, divide, or chew 2
• Monitor for suicidal thoughts and behaviors, particularly when initiating treatment 2
• Discontinuation rates due to adverse reactions are approximately 9% (compared to 5% with placebo), with insomnia and headache being the most common reasons 2

Alternative and Adjunctive Treatments

SSRIs as Alternative Pharmacotherapy

• Selective serotonin reuptake inhibitors (fluoxetine, sertraline) are effective for treating depressive symptoms in SAD 9
• SSRIs can be used when light therapy is not tolerated or accessible 9

Cognitive Behavioral Therapy

• CBT specifically adapted for SAD is an evidence-based treatment option that can be used alone or in combination with light therapy or medication 9, 3
• Approximately 14 sessions over 4 months (60-90 minutes each) is the recommended duration 10

Lifestyle Interventions

• Increasing exercise and exposure to natural light are recommended adjunctive measures 3
• These interventions should complement, not replace, first-line treatments 3

Treatment Algorithm

1. Start with light therapy (10,000 lux for 30 minutes each morning) as first-line treatment for acute SAD episodes 1
2. For prevention in patients with recurrent SAD, consider bupropion XL 300 mg daily initiated in autumn 2, 3
3. If light therapy is ineffective or not tolerated, switch to bupropion XL or an SSRI 9, 3
4. For partial response, combine light therapy with pharmacotherapy (bupropion or SSRI) 7
5. Add CBT for patients requiring additional support or those with residual symptoms 9

Critical Pitfalls to Avoid

• Do not use evening light therapy, as morning administration is superior and evening exposure may disrupt sleep 1
• Do not overlook hypomania risk, especially in patients with bipolar disorder or family history of bipolar disorder 1, 7
• Do not prescribe bupropion doses above 300 mg/day for SAD, as higher doses were not assessed in SAD trials and increase seizure risk 2
• Do not discontinue bupropion abruptly; taper to 150 mg daily before stopping 2