Generic and health-related quality of life in patients with seasonal and nonseasonal depression

Although a relatively large body of research has now accumulated concerning the relationship between quality of life (QoL) and nonseasonal depression, there is a dearth of information about QoL in seasonal affective disorder (SAD). The aim of this study was to compare perceived levels of broad ('generic') and health-related QoL in patients with seasonal and nonseasonal depression. Participants were 72 patients with SAD enrolled in an on-going multicentre study in Canada, and 72 patients with nonseasonal major depressive disorder (MDD) matched for severity of depression attending an outpatient psychiatric clinic in Vancouver, British Columbia. All participants completed two measures of QoL (the 20-item Medical Outcomes Study [MOS] Short-Form General Health Survey [SF-20] and the Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q]) at baseline prior to treatment. The results of the study indicated that both generic and health-related QoL were compromised in patients with SAD compared with general population norms. For example, mean Q-LES-Q scores (range 0-100, where higher scores indicate better QoL) were 44%, compared with scores of 83% reported for the general population. Patients with nonseasonal depression showed significantly poorer functioning in several domains on the SF-20, but no significant differences in Q-LES-Q scores emerged. Perceived QoL is impaired in patients with SAD. Degree of impairment between seasonal and nonseasonal depressives is equivalent when assessed using the Q-LES-Q, but significant inter-group differences are apparent in SF-20 domain scores. Future research is required to determine whether perceived QoL is improved by treatment interventions for seasonal depression such as light therapy or antidepressant medication.     

The effects of seasons and light therapy on G protein levels in mononuclear leukocytes of patients with seasonal affective disorder

BACKGROUND: Information-transducing heterotrimeric G proteins have been implicated previously in the mechanism of action of mood stabilizers and in the pathophysiology of mood disorders. Mononuclear leukocytes of patients with unipolar and bipolar depression have been characterized by reduced measures of the stimulatory and inhibitory G proteins. In this study, patients with seasonal affective disorder (SAD) were measured for mononuclear leukocyte G protein levels while depressed during the winter, following light therapy, and in remission during the summer. METHODS: Twenty-six patients with SAD and 28 healthy subjects were assessed in the study. The immunoreactivities of Gs alpha, Gi alpha, and Gbeta subunit proteins were determined by Western blot analysis of mononuclear leukocyte membranes with selective polyclonal antibodies for the various G subunit proteins, followed by densitometric quantitation using an image analysis system. RESULTS: Untreated patients with SAD and winter, atypical-type depression showed significantly reduced mononuclear leukocyte immunoreactive levels of Gs alpha and Gi alpha proteins, similar to previous observations in patients with nonseasonal major depression. The reduced G protein levels were normalized with 2 weeks of light therapy. The same patients while in remission during the summer had G protein levels that were similar to those of healthy subjects. CONCLUSIONS: G protein-immunoreactive measures in patients with SAD are suggested as a state marker for winter depression, which is normalized by light treatment and during the summer. We speculate that light may exert its effects via normalization of transducin (Gt protein) levels, which are thought to be reduced in winter depression.     

Core body temperature in patients with seasonal affective disorder and normal controls in summer and winter

The rationale for phototherapy in seasonal affective disorder (SAD) was originally based on the notion that SAD patients were light deprived during the wintertime and needed more light. We previously found normal temperature profiles of untreated SAD patients during the winter, and that phototherapy significantly enhanced the amplitude of the circadian temperature profile in SAD patients during the winter (Rosenthal et al 1990). We hypothesized that summer would act similarly on the temperature rhythm of these patients. In this study we examined the temperature data from SAD patients and normal controls during the summer and compared it to the results of our previous study. We found identical profiles for SAD patients and normal controls during the summer and that summer significantly lowered the overall temperature profiles of both groups and did not alter the amplitudes. These results raise questions about the validity of the current theories of the mechanism of light therapy.     

The prevalence of seasonal affective disorder in The Netherlands: a prospective and retrospective study of seasonal mood variation in the general population.

BACKGROUND: The aim of the present study was to assess the prevalence of seasonal affective disorder (SAD) in The Netherlands. METHODS: The subjects (n = 5356), randomly selected from community registers, were given the Seasonal Pattern Assessment Questionnaire and the Centre for Epidemiological Studies Depression Scale over a period of 13 months. The response rate was 52.6%. RESULTS: Three percent of the respondents met the criteria for winter SAD, 0.1% for summer SAD. The criteria for subsyndromal SAD, a milder form of SAD, were met by 8.5%, 0.3% of whom showed a summer pattern. Younger women received a diagnosis of SAD more often than men or older women. CONCLUSIONS: SAD subjects were significantly more often unemployed or on sick leave than other subjects. Respondents who met winter SAD criteria were significantly more depressed than healthy subjects, in both winter and summer. Finally, month of completion had no influence on the number of subjects meeting the SAD criteria.     

Seasonal differences in the diurnal pattern of cortisol secretion in healthy participants and those with self-assessed seasonal affective disorder

This study compared the daily pattern of free salivary cortisol secretion in winter and in summer between two groups; participants with self-assessed seasonal affective disorder (SAD) and age- and sex-matched healthy controls. Fifty-two participants completed the study with an equal number in each group. The diurnal pattern of cortisol secretion was assessed across two consecutive weekdays in summer, and two in winter, with conditions being counterbalanced. On each study day participants collected multiple saliva samples in the domestic setting to capture the cortisol awakening response (CAR) and declining levels across the day. In addition, perceived stress, anxiety, depression, state stress and state arousal were assessed using validated questionnaires. There was no evidence for any seasonal changes in psychological data or cortisol pattern for the healthy control population. In summer, self-assessed SAD and control participants had similar psychological and cortisol profiles. In winter however, SAD participants reported greater depression, stress and anxiety, and lower levels of arousal. Furthermore, the CAR was significantly attenuated in SAD participants during winter months. There was no difference in cortisol levels during the rest of the day between controls and SAD participants in winter. In line with the above findings and previous research, there was an inverse relationship between the increase in cortisol following awakening and a measure of seasonality in winter. Furthermore in winter, a general dysphoria construct correlated inversely with the CAR, indicating that participants reporting greater depression, stress and anxiety and lower arousal, exhibited lower CARs. In conclusion, during the shortened photoperiod in winter, the cortisol response to awakening is attenuated in participants with self-assessed SAD in comparison to controls. These findings contribute to the understanding of the physiology of SAD.     

Seasonal independence of low prolactin concentration and high spontaneous eye blink rates in unipolar and bipolar II seasonal affective disorder

Twenty-four subjects with seasonal affective disorder (SAD: bipolar II, n = 14; unipolar, n = 10) and 20 normal controls were assessed for early follicular basal serum prolactin (PRL) concentration in winter and summer. Luteal basal PRL concentration was assessed in winter. The PRL values represented the mean of three values derived during a 45-minute period. A subset of 17 subjects with SAD and 11 controls were also assessed for spontaneous eye blinking via a polygraphic recording in winter and summer. In winter, compared with controls, subjects with SAD were characterized by significantly lower follicular (10.1 vs 4.5 micrograms/L, respectively) and luteal (14.4 vs 7.4 micrograms/L, respectively) PRL values and by significantly higher eye blink rates (30 vs 61 blinks per 3 minutes, respectively). In summer, controls and subjects with SAD showed similar significant differences in follicular PRL values (9.3 vs 3.9 micrograms/L, respectively) and eye blink rates (25 vs 67 blinks per 3 minutes, respectively). No significant differences in PRL values or eye blink rates were found between the bipolar II and unipolar forms of SAD in either season. Results were discussed in terms of dopamine functioning.     

Thermoregulatory response to thermal challenge in seasonal affective disorder: a preliminary report

It has recently been proposed that alterations in central dopamine (DA) functional activity may, in part, account for certain behavioral changes observed in seasonal affective disorder (SAD) during the winter. To explore this possibility, a preliminary study of thermoregulatory heat loss to an endogenous heat challenge--a strongly DA-dependent process--was undertaken in groups of four SAD woman and four nonpsychiatric control women across three conditions (winter, after successful phototherapy, and summer). Homeostatic heat loss during recovery from heat challenge in SAD, but not in control, subjects was found to be a significant function of light condition and of clinical state. Thermoregulatory heat loss in SAD subjects was significantly blunted in winter during depression, was similar in efficiency to control subjects after a successful antidepressant response to phototherapy, and tended to be more efficient than controls in summer during a euthymic state. Results raise the possibility that a common effect of phototherapy and summer light conditions is a facilitation of central DA activity in SAD.     

Prevalence of seasonal affective disorder at four latitudes

The Seasonal Pattern Assessment Questionnaire (SPAQ) was mailed to a sample population balanced for sex and randomly selected from local telephone directories in four areas: Nashua, NH, New York, NY, Montgomery County, MD, and Sarasota, FL. On the basis of responses to this questionnaire, prevalence rates of winter seasonal affective disorder (winter SAD), summer seasonal affective disorder (summer SAD), and subsyndromal winter SAD were estimated for the four areas. Rates of winter SAD and subsyndromal SAD were found to be significantly higher at the more northern latitudes, while no correlation was found between latitude and summer SAD. The positive correlation between latitude and prevalence of winter SAD applied predominantly to the age groups over 35.     

Photopic and scotopic light detection in patients with seasonal affective disorder and control subjects.

BACKGROUND: Retinal sensitivity may play a role in the pathogenesis of seasonal affective disorder (SAD) and response to light therapy. METHODS: Using a dark adaptation procedure, SAD patients and normal control subjects were tested in the winter and summer, with patients retested after light treatment. The eyes were preadapted to bright light followed by 30 min in darkness, during which subjects detected a dim signal titrated around the detection threshold. Photopic (cone-mediated) and scotopic (rod-mediated) components of the data were identified by nonlinear exponential curve fits to successive threshold estimates. RESULTS: Patients (n = 24) showed significantly lower cone and rod thresholds in the summer than winter, while control subjects (n = 12) showed a similar trend. Relative to the control subjects, however, patients were supersensitive in winter (lower cone final threshold, faster rod recovery). Clinical responders to morning light showed a small summer-like increase in cone sensitivity, whereas nonresponders became subsensitive. In comparison to darker-eyed patients, blue-eyed patients showed a larger summertime increase in cone sensitivity and a similar trend after response to morning light. CONCLUSIONS: Heightened retinal sensitivity with increased light exposure, and supersensitivity of patients relative to control subjects in winter, may play roles in the pathogenesis of winter depression and the action of therapeutic light.     

Seasonal panic disorder: a possible variant of seasonal affective disorder.

The present communication concerns a 30 year-old female patient with panic disorder in whom panic attacks appeared to be seasonally-related. Characteristically, attacks were more frequent and severe during the months of October to May with spontaneous remissions during the months of June to September. Since 70% of patients with seasonal affective disorder (SAD), a variant of affective illness characterized by recurrent winter depressions with remissions in summer, suffer from anxiety disorders, we propose that seasonal panic disorder may be a variant of SAD. Since SAD is associated with phase delay of circadian rhythms, some forms of panic disorder may be related to phase instability of circadian rhythms. Moreover, since administration of artificial bright light therapy is currently the most effective treatment for SAD, it is suggested that patients with panic disorder should be questioned as to whether their symptoms are seasonally related. If a positive association is established, these patients should be offered treatment with light therapy prior to or coincident with the institution of pharmacotherapy.     

Cross-national survey of winter and summer patterns of mood seasonality: a comparison between Italy and India

The aim of this study was to compare winter and summer patterns of mood seasonality in university students living at different latitudes: Bologna, 44° N (Italy), and Kalyani, 22° N (India). To assess the mood seasonality, the Seasonal Pattern Assessment Questionnaire was administered to 1370 university students (808 females, 562 males; 862 Italians, 508 Indians), ranging in age between 18 and 28 years. A significantly higher Global Seasonality Score was observed in females than males as well as in Italians than Indians. The estimated rates of summer seasonal affective disorder (SAD) and summer subsyndromal SAD were higher in Indians, whereas Italians reported higher percentage of winter SAD and winter subsyndromal SAD. The present findings are discussed in relation to the different environmental features between the 2 countries: high summer temperature in India and short winter photoperiod along with its great excursion over the year in Italy.     

Abnormal serotonergic control of prolactin and cortisol secretion in patients with seasonal affective disorder

The effects of the serotonergic agent d,l-fenfluramine (60 mg PO) or a placebo on serum prolactin (PRL) and cortisol levels were evaluated in seven patients (five men and two women) with seasonal affective disorders (SAD) and in eight normal controls (eight men and two women). Both groups were tested in fall/winter when patients with SAD suffered depressive symptoms and in spring/summer, when patients were euthymic. Spring/summer and fall/winter tests gave similar results. PRL and cortisol patterns were similar in all subjects after placebo, whereas both hormonal responses to d,l-fenfluramine were significantly lower in patients with SAD than in normal controls. Correlation studies between the two hormonal responses revealed that on both periods the amplitudes of PRL and cortisol increments were significantly and positively correlated in patients with SAD. These data show diminished serotonergic responsiveness in SAD regardless of the actual depressive status of the patients. They are consistent with a decrease of central serotonergic activity in SAD.     

The four seasons: food intake frequency in seasonal affective disorder in the course of a year

Patients with seasonal affective disorder (SAD) report atypical symptoms of increased appetite, particularly "carbohydrate craving," increased body weight, and sleepiness, during their winter depression. To document feeding behavior in detail, a Food/Drink Frequency Questionnaire (FDFQ) was given to female control subjects and SAD patients at each of the four seasons. SAD patients consumed carbohydrate-rich foods (starch and not sweets) more often than controls (annual mean) and also showed a seasonal rhythm with maximum values in winter and minimum values in summer. In contrast, protein-rich food intake was identical in both groups and did not show seasonal variation. Fiber-rich food intake was also increased in SAD patients. SAD patients ate more meals per day, both at breakfast and in the second half of the day. Again, SAD patients showed seasonal changes of meal number with a minimum in summer. Body weight and body mass index did not undergo significant seasonal changes in the group as a whole, nor did SAD patients differ from controls. These atypical symptoms in SAD can be interpreted as a "medial hypothalamus syndrome" involving alpha 2-noradrenergic and serotonergic mechanisms.     

Mood regulation in seasonal affective disorder patients and healthy controls studied in forced desynchrony

In healthy subjects, both the duration of wakefulness and the circadian pacemaker have been demonstrated to be involved in the regulation of mood. Some features of affective disorders suggest that these two factors also play a role in the dysregulation of mood. In particular, disturbances of the circadian pacemaker have been proposed to be a pathogenetic factor in Seasonal Affective Disorder, winter type (SAD). This report presents a test of this proposition. To this end seven SAD patients and matched controls were subjected to a 120-h forced desynchrony protocol, in which they were exposed to six 20-h days. This protocol enables us to discriminate the extent to which the course of mood is determined by the imposed 20-h sleep-wake cycle from the influence of the circadian pacemaker on that course. Patients participated during a depressive episode, after recovery upon light therapy and in summer. Controls were studied in winter and in summer. Between SAD patients and controls no significant differences were observed in the period length nor in the timing of the endogenous circadian temperature minimum. In both groups, sleep-wake cycle- and pacemaker-related components were observed in the variations of mood, which were not significantly different between conditions.     

An epidemiological study on gender differences in self-reported seasonal changes in mood and behaviour in a general population of northern Sweden

Gender differences have been reported regarding symptoms, prevalence and heritability of seasonal affective disorders (SAD). We focus on gender aspects in this study of self-reported seasonal changes in mood and behaviour in a general population. The Seasonal Pattern Assessment Questionnaire (SPAQ) was completed by 2620 adults (55.6% women) aged 35-85 years, enrolled in the Betula prospective random cohort study of Ume?, Sweden. October to February turned out to be suitable winter months. SAD was found in 2.2% and sub-syndromal SAD (S-SAD) in 5.7%. Women had about 1.5 times higher prevalences than men, and seasonality problems decreased with age in both genders. Preference for eating least was distributed with a peak in summer, whereas preference for eating most had a major peak in winter (winter eaters) and a minor peak in summer (summer eaters). Significantly more of winter eaters in women, and significantly more of summer eaters in men, felt worst in winter. Seasonal change in weight was considered significantly as a problem by women but not by men. Winter behaviour of sleeping most was considered significantly as a problem by men but not by women. Women reacted significantly to temperature-related changes (negatively to cold/short days and positively to hot/long days), whereas men reacted significantly to sunshine-related changes (negatively to cloudy days and positively to sunny days). Subtle gender differences may thus underlie the pathophysiology of seasonal problems. Studies of an eventual efficacy of treating SAD women with raised ambient temperature, and gender-specific comparisons with other therapies, would be of interest.     

The relationship between clinical outcomes and quality of life in first‐episode mania: a longitudinal analysis

Objectives: Despite growing attention to the relationship between bipolar disorder (BD) and quality of life (QoL), there remains a lack of information about QoL in the early stages of BD, and about the course of QoL in people with BD over time. Here, we report on QoL and symptomatic outcomes over a 1.5‐year period in a Canadian sample of first‐episode mania patients. Methods: Patients (n = 63) with DSM‐IV‐TR BD type I recovering from a recent episode of mania were recruited from a university‐based hospital setting in Vancouver, BC, Canada and assessed at six monthly intervals for 18 months. In addition to symptomatic and cognitive assessments, two self‐report QoL scales [the Quality of Life Enjoyment and Satisfaction Questionnaire (Q‐LES‐Q) and the Medical Outcomes Study Short Form 36 (SF‐36)] were administered. Results: Baseline QoL scores were high, with mean Q‐LES‐Q scores at 70% of the maximum possible score; QoL continued to show a trend towards improvement over time. Multiple hierarchical regressions were used to explore predictors of QoL over time, finding that: (i) length of illness and severity of depressive symptoms at baseline predicted Q‐LES‐Q scores at both baseline and six months; (ii) the number of previous depressive episodes and severity of depression at baseline and 12 months all predicted QoL at 12 months; and (iii) only severity of depressive symptoms at 12 months predicted QoL at 18 months. Conclusions: Our observation that QoL in patients who have recently experienced an episode of mania can be relatively preserved offers hope, both for healthcare providers and for those newly diagnosed. Further, that severity of depressive symptoms even in the early stages of the disease was the consistent predictor of QoL suggests that depressive symptoms need to be aggressively treated to improve QoL.     

Patterns of physician and patient rated quality of life during antipsychotic treatment in outpatients with schizophrenia

Quality of life (QoL) in patients with schizophrenia has been assessed both from physician and patient perspectives, but little is known about agreement between these perspectives and predictors of agreement. The aim of this study was to analyze a large sample of patients with schizophrenia to discover patterns of physician and patient-rated QoL in patients with schizophrenia and identify predictors for these patterns. This study (EASE) was designed to investigate the QoL and subjective well-being in out-patients with schizophrenia during antipsychotic treatment in a naturalistic setting. Assessments were carried out at baseline and at 3, 6, 9 and 12 months, using the quality of life scale (QLS) and the subjective well-being on neuroleptics scale (SWN-K). A hierarchical cluster analysis was used to define groups of patients based on the SWN-K and QLS total scores at all visits. 1174 patients were included in the cluster analyses that were based on SWN-K and QLS total scores over time. Four distinct clusters were identified: patients with: (1) continuously high QoL (23.2%), (2) continuously moderate QoL (45.8%), (3) continuously low QoL (11.2%), and (4) improving QoL (19.9%). Clusters 1-3 were stable in terms of QoL, whilst cluster 4 changed towards improvement. Various predictors for the four clusters were identified. In the cluster with improving QoL, the absence of treatment with an oral conventional antipsychotic pre-study and no medication change due to lack of efficacy at baseline were predictors for improvement. In the cluster with continuously high QoL, no medication change due to lack of efficacy and lowest CGI-S scores at baseline were predictors. Oral conventional antipsychotic treatment pre-study was predictive for the cluster with continuously moderate QoL. In the cluster with continuously low QoL, medication change due to lack of efficacy and highest CGI-S scores were predictors. These findings suggest that various factors may predict whether a patient with schizophrenia experiences a continuously high QoL, a continuously moderate QoL, a continuously low QoL, or improving QoL whilst on antipsychotic treatment.     

Atypical pattern of rod electroretinogram modulation by recent light history: A possible biomarker of seasonal affective disorder

Our goal was to challenge both normal controls and patients with seasonal affective disorders (SAD) to various light histories and then measure their retinal response modulation using the electroretinogram (ERG) in both winter and summer. In winter and summer, 11 normal controls and 12 SAD patients were exposed to three different light conditions for 1 h (10,000, 100 and 5 lux) followed by an ERG. Groups showed similar ERG amplitudes in the 100 lux condition. Compared with the 100-lux condition, in controls, the ERG response was significantly increased in the 5-lux condition; in SAD, it was significantly decreased in the 10,000-lux condition. This pattern was present in both seasons. This is the first time a retinal response modulation anomaly has been observed in SAD patients in both the depressed and euthymic states. Retinal response modulation may represent an interesting biomarker of the disease for future research.     

Seasonal affective disorder: spatial organization of EEG power and coherence in the depressive state and in light-induced and summer remission.

The present study analyzed EEG power and coherence in subjects with seasonal affective disorder (SAD) during depressive episodes and during light-induced and summer remission. Baseline EEG activity was recorded during the winter period before light treatment (31 SAD patients, 30 control subjects); after 10 days of 2-h morning light treatment (10 SAD subjects); and during the summer period (14 SAD subjects, 27 control subjects). EEG power and coherence were calculated for the delta, theta-1, theta-2, alpha, beta-1 and beta-2 frequency bands. Compared with control subjects, SAD subjects had lower than normal EEG power in most frequency bands; asymmetrical distribution of delta, theta-1, theta-2 and alpha activity in parietal and temporal regions due to increased EEG power over the left electrode sites; and beta activity in the lateral frontal region due to increased beta power over the right electrode site. The foci of decreased EEG coherence were mainly in the right and left frontal and the right posterior regions. Remitted SAD subjects showed normalization of inter-hemispheric asymmetry in lateral frontal areas; increases of delta, theta-2, and alpha activity compared with control values; theta-1 activity in excess of control values; and disappearance of the foci of decreased coherence in anterior areas of the left hemisphere.