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Objective: In adults with attention-deficit/ hyperactivity disorder (ADHD), a delayed sleep/ activity rhythm and/or seasonal mood symptoms may contribute significantly to core pathology and disability. This study examined whether a chronobiologically based treatment, i.e., morning bright light therapy (LT), might have utility as an adjunctive treatment for adult ADHD in the fall/ winter period., Method: Twenty-nine adults with DSM-IV ADHD were administered a standard 3-week open trial of LT during the fall or winter months. Primary outcome measures included percentage reduction on the Brown Adult ADD Scale and the Conners' Adult ADHD Scale. Secondary measures were decrease in depression scores according to the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder version; improvements on various neuropsychological tests; and shift toward an earlier circadian preference as measured by the Horne-Ostberg Morningness-Eveningness questionnaire. Regression analyses determined which variables at baseline best predicted improvement on a given outcome measure and which variables changed in parallel with one another. The study was conducted from November 2003 through February 2004., Results: Morning bright light therapy was associated with a significant decrease in both subjective and objective measures of core ADHD pathology, improved mood symptoms, and a significant phase advance in circadian preference. Multiple regression showed that the shift toward an earlier circadian preference with LT was the strongest predictor of improvement on both subjective and objective ADHD measures. Neither baseline global seasonality scores nor baseline depression scores strongly predicted LT effects on most measures of ADHD., Conclusion: These findings suggest that during the fall/winter period, LT may be a useful adjunct in many adults with ADHD. Strikingly, the strongest correlate of improvement in core ADHD pathology was a phase advance in circadian preference rather than alleviation of comorbid seasonal affective disorder, suggesting important clinical benefits of LT beyond the treatment of seasonal affective disorder.

Background: Season of birth or seasonal changes in putative etiologic factors are thought to influence the development of several psychiatric illnesses. The aim of this investigation was to examine seasonal differences in the frequency of birth in a clinical sample of patients with seasonal affective disorder (SAD)., Method: 553 outpatients suffering from SAD-DSM-IV-defined depressive disorder with winter-type seasonal pattern-who had been diagnosed and treated at the Department of General Psychiatry (University of Vienna, Austria) between 1994 and 2003, were included in this evaluation. We compared the observed number of births in our sample with expected values calculated from the general population., Results: There was a significant deviation of the observed number of births from the expected values calculated on a monthly basis (p = .009). When comparing quarters (periods of 3 months), we found fewer births than expected in the first quarter of the year and a slight excess of births in the second and third quarters (p = .034). There were also more births in the spring/summer season and fewer than expected in fall and winter (p = .029). Interestingly, patients with melancholic depression were more frequently born in fall/winter and less often in spring/summer compared with patients with atypical depression (p = .008)., Conclusion: Besides genetic factors, season of birth or seasonal changes in environmental factors also could influence the development of SAD. In addition, birth effects seem to be dependent on the symptom profile of the patients, but further studies are needed to elucidate the underlying mechanisms of these observations.

Background: Few studies have compared the psychopathology of patients with seasonal and nonseasonal mood disorders., Method: We compared the psychopathology of a consecutively referred sample of seasonal affective disorder (SAD) outpatients (N = 87) with that of hospitalized suicide attempters who had nonseasonal major depression (N = 65) by using the Comprehensive Psychopathological Rating Scale (CPRS). Diagnoses were made according to DSM-III-R criteria. Data were gathered from October 1992 to April 1996., Results: There were no significant differences in the CPRS total scores of all of the observed items or of the depression subscale items between the groups. The SAD sample had significantly (p <.05) higher scores on 18 reported non-psychotic items than the non-SAD suicide attempters. Eleven CPRS items were independently associated with SAD in a backward logistic regression analysis: the reported items were hostile feelings, indecision (negatively), lassitude, failing memory, increased sleep, muscular tension, loss of sensation or movement, and disrupted thoughts, and the observed items were perplexity, slowness of movement (negatively), and agitation., Conclusion: As compared with non-SAD suicide attempters with major depression, SAD patients have an abundant symptomatology, reflected especially by scores on self-reported items.

Background: Season-related subsyndromal depressive symptoms during winter are common among populations at high latitudes. Both physical exercise and exposure to bright light can relieve the fatigue and downturn of mood associated with the shortening length of day. Serum cholesterol level may be related to changes in mood, but the evidence is contradictory. Our objective was to compare the effect of aerobic exercise with or without bright-light exposure on health-related quality of life, mood, and serum lipids in a sample of relatively healthy adult subjects., Method: A randomized controlled trial was conducted with subjects allocated to group aerobics training in a gym with bright light (2500-4000 lux) (N = 40) or normal illumination (N = 42) or to relaxation/stretching sessions in bright light as a control group (N = 42) twice a week for a period of 8 weeks. Changes in mood were recorded using questionnaires at the beginning of the study, at weeks 4 and 8. and at follow-up 4 months after the study. A blood sample was drawn before and after the 8-week intervention to measure the concentrations of serum lipids., Results: Ninety-eight subjects completed the 8-week study. Both exercise and bright light effectively relieved depressive symptoms. Bright light reduced atypical depressive symptoms more than exercise (p = .03), based on the atypical symptoms subscore of the Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorders Version Self-Rating Format. There were no significant differences between the study groups in the changes in serum lipid levels., Conclusion: Bright light administered twice a week, alone or combined with physical exercise, seems to be a useful intervention for relieving seasonal mood slumps.

Objective: Many patients with seasonal affective disorder (SAD) have dysfunctional eating behaviors. Conversely, many women with bulimia nervosa have marked winter worsening of mood and bulimic symptoms. Controlled studies of light therapy in SAD and in bulimia nervosa have shown beneficial effects on mood and binge/purge symptoms. We explored the clinical use of light therapy in women with SAD who also had comorbid bulimia nervosa., Method: Twenty-two female patients diagnosed using DSM-IV criteria with both bulimia nervosa and major depressive disorder with a seasonal (winter) pattern were treated with an open design, 4-week trial of light therapy (10,000 lux fluorescent light box with an ultraviolet filter, 30 to 60 minutes per day in the early morning). Patients were assessed before and after treatment with depression scales and with binge/purge diaries., Results: Light therapy resulted in significant improvement in mood, with a mean 56% reduction in 29-item Hamilton Rating Scale for Depression scores following treatment (p < .001). The frequency of binges and purges per week also significantly decreased (p < .001) from baseline by a mean of 46% and 36%, respectively. Two (9%) of 22 patients became abstinent of binge/ purge episodes, compared with 10 (45%) of 22 patients who met criteria for remission of depressive symptoms. The light therapy was well tolerated by patients., Conclusion: These results suggest that therapeutic effects of light therapy on mood and bulimic symptoms in patients with SAD and comorbid bulimia nervosa are sustained over at least 4 weeks. However, the low abstinence rate in bulimic symptoms indicates that light therapy may be most effectively used as an adjunctive treatment to medications and/or psychotherapy for bulimia nervosa.

Background: Recent data suggest that winter depression (seasonal affective disorder [SAD]) may be a subtype of affective disorder that is closely related to alcoholism. Dawn simulation has been shown in controlled trials to be effective in SAD. The present study examined the effectiveness of dawn simulation in abstinent alcoholics who met DSM-III-R criteria for major depression, or bipolar disorder, depressed with seasonal pattern., Method: All 12 subjects with winter depression had a history of either alcohol dependence or alcohol abuse according to DSM-III-R and had been abstinent from alcohol for at least 6 months. They also fulfilled criteria for SAD according to Rosenthal and were hypersomnic and drug free. After a 1-week baseline period, the subjects were randomly assigned to a 1-week treatment period at home with either a white 1.5-hour dawn from 4:30 a.m. to 6:00 a.m. peaking at 250 lux or a red 1.5-hour dawn from 4:30 a.m. to 6:00 a.m. peaking at 2 lux. The subjects were told that they would receive daily either a red or a white dawn reaching the same illuminance, an illuminance that would be much dimmer than standard bright light treatment. At the end of each week, the subjects were blindly assessed by a psychiatrist using the Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorder version (SIGH-SAD)., Results: For the 6 subjects completing the white dawn treatment, the mean SIGH-SAD score decreased from 33.0 at baseline to 15.8 after treatment. For the 6 subjects completing the dim red dawn treatment, the mean SIGH-SAD score decreased from 34.3 to 32.7. The mean post-dawn SIGH-SAD score was significantly lower after the white dawn treatment than after the dim red dawn treatment (ANCOVA with baseline SIGH-SAD as the covariate, F = 12.95, p < .01). Superiority of the white dawn was also found by analogous analyses for the Hamilton Rating Scale for Depression (HAM-D) (p < .01) and the SAD Subscale (p < .05)., Conclusion: The present study suggest that dawn simulation may be helpful in decreasing depression in abstinent alcoholics with SAD. Further study is necessary to confirm these preliminary findings and to determine whether dawn simulation might be helpful in preventing relapse in abstinent alcoholics who have SAD.

The complexity of subtyping depression and the implications that such subtyping has on treatment choices are discussed in this article. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) directs clinicians to classify the mood disorders in depressed patients as unipolar, bipolar, due to a general medical condition, or due to substance abuse. The focus of this article is unipolar (major depression and dysthymia) and bipolar I and II disorders with and without feature specifiers for atypical depression, seasonal affective disorder, psychotic depression, and postpartum depression. Anxious depression, which is not a DSM-IV classification, is also reviewed.

Background: Suicidality in seasonal affective disorder (SAD) subjects treated with bright light therapy seems to be a rare phenomenon. We report on three SAD patients with predominant atypical symptoms who presented for treatment in our clinic for SAD. Two suffered from bipolar disorder, one from recurrent major depressive disorder., Method: All subjects were drug-free and treated with bright light therapy as a monotherapy for the first time. Treatment response was assessed weekly by standardized rating instruments, using the Hamilton Rating Scale for Depression (HAM-D) and the HAM-D-SAD addendum for assessment of atypical symptoms., Results: Within the first week after beginning bright light therapy, two subjects attempted suicide. The third patient developed suicidal thoughts that were so acute and overwhelming that we had to discontinue bright light therapy and start with psychopharmacologic treatment in an inpatient setting., Conclusion: It is suggested that bright light-induced amelioration of drive and mood can be dissociated as can be the case in the "critical time" of antidepressant therapy. The authors believe the collection of prevalence data on suicide and SAD would be worthwhile.

Background: Patterns of response to the light box and head-mounted unit (HMUs) in seasonal affective disorder (SAD) appear to differ. The current study employed a "no light" condition to compare the response rates with the light box and HMU against a plausible placebo., Method: Forty-three subjects with DSM-III-R nonpsychotic, unipolar major depression, seasonal subtype, were randomly assigned, in a double-blind manner, to receive 2 weeks of active treatment with a light box (N=9) or HMU (N=12) that emitted no visible light, or 2 weeks of placebo treatment with a light box (N=12) or HMU (N=10) that emitted no visible light. Response was defined as a 50% or greater reduction in both the 17-item "typical" score and 8-item "atypical" score on the Structured Interview Guide for the Hamilton Rating Scale for Depression-SAD version (SIGH-SAD)., Results: Using ANOVA for repeated measures, with change in total SIGH-SAD score as the dependent measure, we found no significant main effect of light (F=0.20, p=N.S.) or unit (F=0.50, p=N.S.), and no interaction (F=0.21, p=N.S.). Using log-linear analysis, we found no significant difference in response rate between the four cells (likelihood ratio chi-square = 2.1, p=N.S.). Using chi-square analysis, we found no significant difference in response rates between patients who received light (48%) versus patients who received no light (41%; chi-square = 0.2, p=N.S.) or between patients who received the light box (38%) versus HMU (50%; chi-square = 0.62, p=N.S.)., Conclusion: The failure to detect any significant difference in efficacy between active and placebo treatments calls into question the specificity of light in light therapy for SAD. Methodological limitations, particularly small sample size, are discussed.

Background: The purpose of the study was to examine whether some individuals who report alcohol dependence consistently deteriorate during the fall and winter months. We also explored whether this deterioration could be attributed to seasonal affective disorder., Method: Veterans Administration inpatients were administered a screening questionnaire concerning seasonal patterns in alcohol use and other variables. Those who suggested a fall-winter pattern were interviewed., Results: Six individuals were identified who met criteria for seasonal alcohol dependence (based on DSM-III-R criteria for seasonal depression). Two case summaries are provided., Conclusion: Evaluation for seasonal affective disorder may be warranted in alcoholic patients. In such cases, light therapy may prove a useful adjunct to conventional treatment.

Background: Bright light therapy has been shown to be effective in treating winter depression. Dawn simulation, a low-illuminance light that gradually increases in intensity while the person sleeps, decreased depression in an uncontrolled study. The present study compares a gradual dawn signal with a hypothesized placebo condition, a rapid dawn signal., Method: In a 4-week, randomized crossover design, nine patients with winter depression were treated with a gradual, 2.5-hour dawn simulation for 1 week and a rapid, 10-minute dawn simulation for 1 week. Both dawns had a maximum illuminance of 275 lux. At the end of each baseline week and treatment week, blind raters assessed the level of depression., Results: Hamilton Rating Scale for Depression mean scores significantly decreased for both the gradual dawn (17.7 to 5.9, p < .05) and the rapid dawn (17.2 to 7.0, p < .05) condition. The improvement was similar for both treatments. Early morning awakening was significantly (p < .01) more common with the gradual dawn (7/9) than with the rapid dawn (1/9) condition., Conclusion: Depression decreased under both dawn simulations. Because the degree of improvement was similar, a placebo effect rather than the efficacy of dawn simulation might explain the results. However, a mere placebo effect is an unlikely explanation. The degree of improvement was similar to that shown in studies of bright light therapy and clearly superior to previous "placebo" control conditions. The side effects from the gradual dawn may have obscured a potential superiority of the gradual dawn over the rapid dawn.