Patient will present as → a 28-year-old woman seen in mid-November with depressed mood, low energy, and loss of interest — the third consecutive winter this has happened. She is sleeping 11 hours a night, craving carbohydrates, and has gained 8 pounds, and her symptoms have fully resolved each spring without treatment. She has never had a depressive episode in summer, and screening for mania is negative. She begins morning bright light therapy (10,000 lux for 30 minutes), and within two weeks her mood, energy, and sleep normalize.
Key Points:
"Seasonal affective disorder" is not a standalone DSM-5 diagnosis — it is major depressive disorder, recurrent, with the seasonal pattern specifier (the specifier can also apply to bipolar I/II).
- Recurrent major depressive episodes with onset and full remission at characteristic times of year — most commonly fall/winter onset with spring remission
- Episodes carry atypical features: hypersomnia, increased appetite with carbohydrate craving, weight gain, and low energy
- More common in women, younger adults, and higher latitudes (less winter daylight)
- ⚠️ Screen for bipolar disorder — the seasonal pattern specifier also applies to bipolar depression, and both antidepressants and light therapy can precipitate mania
DSM-5 Diagnostic Criteria (seasonal pattern specifier)
- A regular temporal relationship between the onset of major depressive episodes and a particular time of the year (most commonly beginning in fall or winter)
- Full remissions (or a switch to mania/hypomania) also occur at a characteristic time of year (most commonly spring)
- In the last 2 years, two seasonal major depressive episodes and no nonseasonal episodes
- Seasonal episodes substantially outnumber any nonseasonal episodes over the patient's lifetime
- Exclude cases better explained by a seasonally linked psychosocial stressor (e.g., seasonal unemployment)
Bright light therapy is first-line for winter-pattern depression — 10,000 lux for 20–30 minutes within an hour of waking; response typically within 1–2 weeks.
- SSRIs (fluoxetine, sertraline) are equally effective first-line alternatives, and CBT tailored to seasonal depression has the most durable benefit across future winters
- Bupropion XL is FDA-approved for PREVENTION — started in early fall before symptoms begin and continued through winter in patients with recurrent seasonal episodes
- ⚠️ Light therapy and antidepressants can precipitate mania — rule out bipolar disorder first; morning timing matters (evening light disrupts sleep)
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Question 1 |
A 30-year-old woman has had major depressive episodes beginning each November and resolving completely each April for the past 3 years, with no depressive episodes at other times. Which additional symptom cluster is most characteristic of her condition?
Hypersomnia, carbohydrate craving, and weight gain | |
Early-morning awakening, anorexia, and weight loss Hint: These are melancholic features — seasonal winter depression classically shows the reverse (atypical) pattern. | |
Flashbacks, hypervigilance, and avoidance Hint: These are PTSD symptoms, which require a qualifying trauma. | |
Compulsions, intrusive thoughts, and rituals Hint: These define obsessive-compulsive disorder, not a depressive episode. | |
Elevated mood, decreased need for sleep, and pressured speech Hint: These are manic symptoms — her screening is for depression with seasonal onset. |
Question 1 Explanation:
Winter-pattern seasonal depression classically presents with atypical features: hypersomnia rather than insomnia, increased appetite with carbohydrate craving, and weight gain rather than loss. The seasonal pattern specifier requires episodes that begin and fully remit at characteristic times of year, two seasonal episodes with no nonseasonal episodes in the last 2 years, and a lifetime predominance of seasonal episodes. It is more common in women, younger adults, and at higher latitudes.
Question 2 |
For major depressive disorder to carry the seasonal pattern specifier, DSM-5 requires which of the following?
Two seasonal major depressive episodes and no nonseasonal episodes in the last 2 years | |
A single winter depressive episode lasting at least 2 weeks Hint: One episode cannot establish a recurring seasonal relationship — the specifier requires a 2-year pattern. | |
Chronic low-grade depression for 2 years that worsens each winter Hint: Chronic low-grade depression for 2 years is persistent depressive disorder — the seasonal specifier requires discrete episodes with full remission. | |
Depressive episodes triggered by winter seasonal unemployment Hint: DSM-5 specifically excludes episodes better explained by seasonally linked psychosocial stressors. | |
Depressive episodes in at least 5 consecutive winters Hint: The requirement is 2 consecutive years, not 5. |
Question 2 Explanation:
The seasonal pattern specifier requires a regular temporal relationship between episode onset and time of year, full remission at a characteristic time of year, two seasonal major depressive episodes with no nonseasonal episodes in the last 2 years, and seasonal episodes substantially outnumbering nonseasonal episodes over the lifetime. Episodes explained by seasonal psychosocial stressors (like seasonal unemployment) do not count. Remember the specifier also applies to bipolar disorders — spring switches into mania occur.
Question 3 |
The most appropriate first-line treatment for winter-pattern major depressive disorder with seasonal pattern is:
Bright light therapy, 10,000 lux for 20–30 minutes each morning | |
Bright light therapy for 30 minutes each evening before bed Hint: Evening light disrupts circadian rhythm and sleep — light therapy is delivered in the morning, within an hour of waking. | |
Scheduled alprazolam through the winter months Hint: Benzodiazepines have no role in depressive disorders and carry dependence risk. | |
Quetiapine monotherapy Hint: Antipsychotic monotherapy is not first-line for uncomplicated unipolar seasonal depression. | |
Watchful waiting until spring remission Hint: Episodes last the entire winter and impair functioning — effective, low-risk treatment exists. |
Question 3 Explanation:
Morning bright light therapy (10,000 lux for 20–30 minutes within an hour of waking) is first-line for winter-pattern seasonal depression, with response typically in 1–2 weeks. SSRIs and CBT tailored to seasonal depression are effective alternatives, and bupropion XL is FDA-approved for prevention when started in early fall before symptoms begin. Screen for bipolar disorder first — both light therapy and antidepressants can precipitate mania.
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