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seasonal affective disorder

 
Medical Encyclopedia: Seasonal Affective Disorder
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More about Seasonal Affective Disorder:
Causes and symptoms
Diagnosis
Treatment
Prognosis
Resources

Definition

Seasonal affective disorder (SAD) is a form of depression most often associated with the lack of daylight in extreme northern and southern latitudes from the late fall to the early spring.

Description

Although researchers are not certain what causes seasonal affective disorder, they suspect that it has something to do with the hormone melatonin. Melatonin is thought to play an active role in regulating the "internal body clock," which dictates when humans feel like going to bed at night and getting up in the morning. Although seasonal affective disorder is most common when light is low, it may occur in the spring, and it is then often called reverse SAD.

— Robert Scott Dinsmoor


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Dictionary: seasonal affective disorder
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n. (Abbr. SAD)
A form of depression occurring at certain seasons of the year, especially when the individual has less exposure to sunlight.


Britannica Concise Encyclopedia: seasonal affective disorder
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Cyclical depression occurring in winter, apparently caused by insufficient sunlight. It is most common in places at high latitudes and therefore with long winters and very short daylight hours. Symptoms can include all those of major depression, and there is a risk of suicide. The cause may be related to regulation of the body's temperature and hormones and may involve the pineal gland and melatonin. Exposure to intense full-spectrum light from a set of fluorescent bulbs in a light box with a diffusing screen has proved effective as treatment. Dawn simulation (exposure to low light levels in the final sleep period) and negative-ion therapy can also help.

For more information on seasonal affective disorder, visit Britannica.com.

Food and Fitness: seasonal affective disorder
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SAD

A mood disorder characterized by mild depression and lethargy, apparently triggered by a reduction in the number of daylight hours in autumn and winter. It is often accompanied by intense cravings for sugary foods that might alleviate feelings of depression. SAD sufferers usually lose their cravings when exposed to special, bright artificial lighting for one or two hours each day.

Dental Dictionary: seasonal affective disorder
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n
SAD

A mood disorder associated with the shorter days and longer nights of autumn and winter. Symptoms include lethargy, depression, social withdrawal, and work difficulties.

Alternative Medicine Encyclopedia: Seasonal Affective Disorder
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Definition

Seasonal affective disorder (SAD) is a form of depression most often associated with lack of daylight in extreme northern and southern latitudes from the late fall to the early spring.

Description

Although researchers are not certain what causes seasonal affective disorder, they suspect that it has something to do with the hormone melatonin. Melatonin is thought to play an active role in regulating the "internal body clock," which dictates when humans feel like going to bed at night and getting up in the morning. Although seasonal affective disorder is most common when light is low, it may occur in the spring, which is often called reverse or spring-onset SAD. Recent research also indicates that SAD has a genetic factor; about 29% of cases in the United States run in families.

Causes & Symptoms

The body produces more melatonin at night than during the day, and scientists believe it helps people feel sleepy at nighttime. There is also more melatonin in the body during winter, when the days are shorter. Some researchers believe that excessive melatonin release during winter in people with SAD may account for their feelings of drowsiness or depression. One variation on this idea is that people's internal clocks may become out of sync during winter with the light-dark cycle, leading to a long-term disruption in melatonin release. Another possible cause of SAD is that people may not adjust their habits to the season, or sleep more hours when it is darker, as would be natural.

Seasonal affective disorder, while not an official category of mental illness listed by the American Psychiatric

SYMPTOMS OF SEASONAL AFFECTIVE DISORDER (SAD)
Increased sleep
Depression
Lethargy
Weight gain
Carbohydrate cravings
Decreased sex drive
Avoidance of social interaction
Difficulty performing daily tasks
Crying fits
Suicidal thoughts

Association, is estimated to affect 6% of the American population. Another 25 million Americans may have a mild form of SAD, sometimes called the "winter blues" or "winter blahs." The risk of SAD increases the further from the equator a person lives; one early study of SAD found a 1.4% incidence of the disorder among people living in Florida, compared with 9.7% among residents of New Hampshire. Other factors that influence the incidence and severity of SAD are sex and age. Women are more likely than men to develop SAD, but men with the disorder are more severely depressed than most women who have it. SAD appears to decrease in severity with age; the elderly have milder SAD symptoms than adolescents.

Comparative studies indicate that the incidence of SAD in the United States and Canada is about twice as high as in European countries at the same latitudes north of the Equator. These findings suggest that cultural factors are also involved in the disorder.

The symptoms of SAD are similar to those of other forms of depression. People with SAD may feel sad, irritable, or tired, and may find themselves sleeping too much. They may also lose interest in normal or pleasurable activities (including sex), become withdrawn, crave carbohydrates, and gain weight.

Diagnosis

Doctors usually diagnose seasonal affective disorder based on the patient's description of symptoms, including the time of year they occur. There is also a diagnostic questionnaire called the Seasonal Pattern Assessment Questionnaire, or SPAQ, used in all Canadian university hospitals and widely used in the United States to assess SAD patients.

Treatment

The first-line treatment for seasonal affective disorder is light therapy (also known as phototherapy). The most commonly used phototherapy equipment is a portable lighting device known as a light box. The box may be mounted upright to a wall or slanted downward toward a table. The patient sits in front of the box for a pre-prescribed period of time (anywhere from 15 minutes to several hours). Some patients with SAD undergo light therapy sessions two or three times daily, others only once. The time of day and the number of times treatment is administered depend on the physical needs and lifestyle of the patient. Light therapy treatment for SAD typically begins in the fall as the days begin to shorten, and continues throughout the winter and possibly the early spring.

The light from a slanted light box is designed to fall on the table supporting the box, so patients may look down to read or do other sedentary activities during therapy. Patients using an upright light box must face the light source (although they need not look directly into the light). The light sources in these light boxes typically range from 2,500 to 10,000 lux (in contrast, average indoor lighting is 300 to 500 lux; a sunny summer day is about 100,000 lux).

A recent British study suggests that dawn simulation, a form of light therapy in which the patient is exposed to white light of gradually increasing brightness (peaking at 250 lux after 90 min) may be even more effective in treating SAD than exposure to bright light. Dawn simulation is started around 4:30 or 5 o'clock in the morning while the patient is still asleep.

Patients with eye problems should see an ophthalmologist regularly both before and during light therapy. Because some UV rays are emitted by the light boxes used in phototherapy, patients taking photosensitizing medications and those who have sun-sensitive skin should consult with a health care professional before beginning treatment. Patients with medical conditions that make them sensitive to UV rays should also see a doctor before starting phototherapy.

Light therapy appears to be safe for most people. However, it can cause side effects of eyestrain, headaches, insomnia, fatigue, sunburn, and dry eyes and nose in some patients. Most of these effects can be managed by adjusting the timing and duration of light therapy sessions. A strong sun block and eye and nose drops can alleviate the others.

Recently, researchers have begun testing whether people who do not completely respond to light therapy can benefit from tiny doses of the hormone melatonin to reset the body's internal clock. Early results look promising, but the potential benefits must be confirmed in larger studies before this type of treatment becomes widely accepted.

Allopathic Treatment

Like other types of mood disorders, seasonal affective disorder may also respond to medication and psychotherapy. Common drugs prescribed for mood disorders are:

A number of psychotherapy approaches are useful as well. Interpersonal psychotherapy helps patients recognize how their mood disorder and their interpersonal relationships interact. Cognitive-behavioral therapy explores how the patient's view of the world may be affecting mood and outlook.

A new treatment for SAD that is still in the experimental phase as of 2001 is the use of high-density negative air ionization.

Expected Results

Most patients with seasonal affective disorder respond to light therapy, dawn simulation, and/or antidepressant drugs. Others respond to sleeping more hours in a dark room. Some researchers estimate that as much as 9.5 hours of sleep are important in winter months and that getting more sleep will increase the person's levels of natural melatonin.

Resources

Books

Lam, Raymond, ed. Seasonal Affective Disorder and Beyond: Light Treatment for SAD and Non-SAD Conditions. Washington, DC: American Psychiatric Press, 1998.

Partonen, Timo, and Andres Magnusson, eds. Seasonal Affective Disorder: Practice and Research. Oxford, UK: Oxford University Press, 2001.

Peters, Celeste A. Don't Be SAD: Your Guide to Conquering Seasonal Affective Disorder. Calgary, Alberta: Good Health Books, 1994.

Rosenthal, Norman. Winter Blues: Seasonal Affective Disorder—What It Is and How to Overcome It. New York: Guilford Press, 1998.

Periodicals

Anderson, Janis L., and Gabrielle I. Warner. "Seasonal Depression." Harvard Health Letter (February 1996): 7-8.

Eagles, John M. "SAD—Help arrives with the dawn?" Lancet 358 (December 22, 2001): 2100.

Singer, Ethan A. "Seasonal Affective Disorder: Autumn Onset, Winter Gloom." Clinician Reviews 11 (November 2001): 49-54.

"Winter Depression: Seeing the Light." The University of California Berkeley Wellness Letter (November 1996): 4.

Organizations

National Depressive and Manic Depressive Association. 730 N. Franklin Street, Ste. 501, Chicago, IL 60610. (312) 642-0049.

National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (301) 443-4513. (888) 826-9438. .

Society for Light Treatment and Biological Rhythms. 824 Howard Ave., New Haven, CT 06519. Fax (203) 764-4324. .

[Article by: Paula Ford-Martin; Rebecca J. Frey, PhD]

 
Columbia Encyclopedia: seasonal affective disorder
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seasonal affective disorder (SAD), recurrent fall or winter depression characterized by excessive sleeping, social withdrawal, depression, overeating, and pronounced weight gain. SAD effects an estimated 6% of Americans; for reasons not yet understood, 80% of those affected are women. Most children who are affected have a close relative who also has SAD or another psychiatric condition. The disorder particularly affects people who live in the upper latitudes.

Although the mechanism of the disorder is not perfectly understood, it is known to be a reaction to the biological effects of light on the body (see biorhythm). Daily, or circadian, rhythms help animals keep track of the seasonal changes in the environment, such as the shortening of days in winter, so that they can make the adaptive changes necessary for their survival in each season. Two substances, the hormone melatonin and the neurotransmitter serotonin, are a part of this process and are being studied for a possible role in SAD. Melatonin is secreted by the pineal gland, which is in turn controlled by an area (the suprachiasmatic nuclei) of the hypothalamus; the hypothalamus, among other things, performs a clocklike function in the body. The eye's retinal nerves are connected to this area. Melatonin is secreted chiefly at night, and its secretion is suppressed by light. Secretion of the neurotransmitter serotonin declines in the winter and may undergo abnormal declines in those with SAD; concentrations of serotonin are increased by bright light. Serotonin is especially active in the hypothalamus. Decreased sensitivity of the retina has also been implicated as a cause of SAD.

Treatment with bright light (about five to twenty times brighter than normal lighting) often alleviates symptoms within a period of days. Unwieldy lighting paraphernalia has given way to smaller, portable light boxes and lighted visors. Doses range from 30 minutes to a few hours per day, often undergone in the morning to simulate the dawn.

Wikipedia: Seasonal affective disorder
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Seasonal Affective Disorder (SAD), also known as winter depression or winter blues, is a mood disorder in which people who have normal mental health throughout most of the year experience depressive symptoms in the winter or, less frequently, in the summer,[1] spring or fall, repeatedly, year after year. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), SAD is not a unique mood disorder, but is "a specifier of major depression".[2]

The US National Library of Medicine notes that "some people experience a serious mood change when the seasons change. They may sleep too much, have little energy, and crave sweets and starchy foods. They may also feel depressed. Though symptoms can be severe, they usually clear up."[3] The condition in the summer is often referred to as Reverse Seasonal Affective Disorder, and can also include heightened anxiety.[4] It has been estimated that 1.5 to 9 percent of adults in the US experience SAD.[5]

There are many different treatments for classic (winter-based) seasonal affective disorder, including light therapy with bright lights, antidepressant medication, cognitive-behavioral therapy, ionized-air administration,[6] and carefully timed supplementation of the hormone melatonin.[7]

Contents

Symptoms

Symptoms of SAD may consist of: difficulty waking up in the morning, tendency to oversleep as well as to overeat, and especially a craving for carbohydrates, which leads to weight gain. Other symptoms include a lack of energy, difficulty concentrating on completing tasks, and withdrawal from friends, family, and social activities. All of this leads to the depression, pessimism, and lack of pleasure which characterize a person suffering from this disorder.

People that experience Reverse SAD (spring and summer depression) show symptoms of insomnia, anxiety, irritability, decreased appetite, weight loss, and an increased sex drive.[citation needed] RSAD can also manifest depression, which makes it difficult to diagnose this rare affliction.

Diagnostic criteria

According to the American Psychiatric Association DSM-IV,[8] criteria, Seasonal Affective disorder is not regarded as a separate disorder, but is called a 'course specifier' and may be applied as an added description to the pattern of Major Depressive Episodes in patients with Major Depressive Disorder or patients with Bipolar Disorder. The Seasonal Pattern Specifier must meet four criteria: depressive episodes at a particular time of the year; remissions or mania/hypomania also at a characteristic time of year; these patterns must have lasted two years with no nonseasonal major depressive episodes during that same period; and these seasonal depressive episodes outnumber other depressive episodes throughout the patient's lifetime. The Mayo Clinic[4] describes three types of Seasonal Affective Disorder, each with its own set of symptoms.

Physiology

Seasonal mood variations are believed to be related to light. An argument for this view is the effectiveness of bright-light therapy.[9] SAD is measurably present at latitudes in the Arctic region, such as Finland (64º 00´N) where the rate of SAD is 9.5%[10] Cloud cover may contribute to the negative effects of SAD.[5]

The symptoms of SAD mimic those of dysthymia or clinical depression. There is also potential risk of suicide in some patients experiencing SAD. One study reports 6 to 35% of sufferers required hospitalization during one period of illness.[5] At times, patients may not feel depressed, but rather lack energy to perform everyday activities.[9]

Various proximate causes have been proposed. One possibility is that SAD is related to a lack of serotonin, and serotonin polymorphisms could play a role in SAD,[11] although this has been disputed.[12] Mice incapable of turning serotonin into N-acetylserotonin (by Serotonin N-acetyltransferase) appear to express "depression-like" behavior, and antidepressants such as fluoxetine increase the amount of the enzyme Serotonin N-acetyltransferase, resulting in an antidepressant-like effect.[13] Another theory is that the cause may be related to melatonin which is produced in dim light and darkness by the pineal gland, since there are direct connections, via the retinohypothalamic tract and the suprachiasmatic nucleus, between the retina and the pineal gland.

Subsyndromal Seasonal Affective Disorder is a milder form of SAD experienced by an estimated 14.3% vs. 6.1% of the U.S. population.[14] The blue feeling experienced by both SAD and SSAD sufferers can usually be dampened or extinguished by exercise and increased outdoor activity, particularly on sunny days, resulting in increased solar exposure.[15] Connections between human mood, as well as energy levels, and the seasons are well documented, even in healthy individuals.

Mutation of a gene expressing melanopsin has been implicated in the risk of having Seasonal Affective Disorder.[16]

Origin

In many species, activity is diminished during the winter months in response to the reduction in available food and the difficulties of surviving in cold weather. Hibernation is an extreme example, but even species that do not hibernate often exhibit changes in behavior during the winter. It has been argued that SAD is an evolved adaptation in humans that is a variant or remnant of a hibernation response in some remote ancestor. [17] Presumably, food was scarce during most of human prehistory, and a tendency toward low mood during the winter months would have been adaptive by reducing the need for calorie intake. The preponderance of women with SAD suggests that the response may also somehow regulate reproduction.[17]

If these interpretations are correct, SAD would not be a dysfunction or disorder as most psychiatrists assume, but rather a normal and expected response to seasonal changes.

Treatment

One type of light therapy lamp

There are many different treatments for classic (winter-based) seasonal affective disorder, including bright light therapy, medication, ionized-air administration, cognitive-behavioral therapy and carefully timed supplementation[citation needed] of the hormone melatonin.

Bright light therapy often includes the use of a lightbox. It emits far more lumens than a customary incandescent lamp but differs from a photographic lightbox in that the emission spectra is more controlled. White light, or "full spectrum" light is usually preferred, although blue light is also used. Lightbox therapy is effective at doses of 2500–10,000 lux,[14] with the patient sitting a prescribed distance, commonly 30–60 cm, in front of the box with her/his eyes open but not staring at the light source.[10] Most treatments use 30–60 minute treatments, however this may vary depending on the situation. Many patients use the light box in the morning, and there is evidence that morning light is superior to evening light, although people can respond to evening light as well.[18] Discovering the best schedule is essential. One study has shown that up to 69% of patients find the treatment inconvenient and as many as 19% stop use because of this.[10] Aerobic exercise during light treatment has been shown to halve the amount of exposure time necessary for therapeutic effect.[citation needed]

Dawn simulation has also proven to be effective; in some studies, there is an 83% better response when compared to other bright light therapy.[10] When compared in a study to negative air ionization, bright light was proven to be 57.1% effective vs. dawn simulation, 49.5%.[6] Patients using light therapy can experience improvement during the first week, but increased results are evident when continued throughout several weeks.[10] Most studies have found it effective without use year round, but rather as a seasonal treatment lasting for several weeks until frequent light exposure is naturally obtained.[9]

SSRI (selective serotonin reuptake inhibitor) antidepressants have proven effective in treating SAD. Bupropion is also effective as a prophylactic.[5] Effective antidepressants are fluoxetine, sertraline, or paroxetine.[9][19] Both fluoxetine and light therapy are 67% effective in treating SAD according to direct head-to-head trials conducted during the 2006 CAN-SAD study.[20] Subjects using the light therapy protocol showed earlier clinical improvement, generally within one week of beginning the clinical treatment.[9]

Negative air ionization, which involves releasing charged particles into the sleep environment, has also been found effective with a 47.9% improvement if the negative ions are in sufficient density (quantity).[21][21][22][22][23][23] Depending upon the patient, one treatment (ie. lightbox) may be used in conjunction with another therapy (ie. medication).[9]

Modafinil may be also an effective and well-tolerated treatment in patients with seasonal affective disorder/winter depression.[24]

Alfred J. Lewy of Oregon Health and Science University in Portland, OHSU, and others see the cause of SAD as a misalignment of the sleep-wake phase contra the period of the body clock, circadian rhythms out of synch, and treat it with melatonin in the afternoon. Correctly timed melatonin administration shifts the rhythms of several hormones en bloc.[25]

Another explanation is that vitamin D levels are too low when people do not get enough Ultraviolet-B on their skin. An alternative to using bright lights is to take vitamin D supplements.[26][27][28][29] However, at least one study did not show a link between SAD and vitamin D levels.[30]

Incidence

Nordic countries

Winter depression is a common slump in the mood of some inhabitants of most of the Nordic countries. It was first described by the 6th century Goth scholar Jordanes in his Getica wherein he described the inhabitants of Scandza (Scandinavia).[31] Iceland, however, seems to be an exception. A study of more than 2000 people there found the prevalence of seasonal affective disorder and seasonal changes in anxiety and depression to be unexpectedly low in both sexes.[32] The study's authors suggested that propensity for SAD may differ due to some genetic factor within the Icelandic population. A study of Canadians of wholly Icelandic descent also showed low levels of SAD.[33] It has more recently been suggested that this may be attributed to the large amount of fish traditionally eaten by Icelandic people, 225 lb per person per year as opposed to about 50 lb in the US and Canada, rather than to genetics.[34] Fish is high in vitamin D. Fish also contains docosahexaenoic acid (DHA), which has been shown to help with a variety of neurological dysfunction.[35]

Other countries

In the United States, a diagnosis of seasonal affective disorder was first proposed by Norman E. Rosenthal, MD in 1984. Rosenthal wondered why he became sluggish during the winter after moving from sunny South Africa to New York. He started experimenting increasing exposure to artificial light, and found this made a difference. In Alaska it has been established that there is a SAD rate of 8.9%, and an even greater rate of 24.9%[36] for subsyndromal SAD. American science fiction-fantasy author Barbara Hambly has had undiagnosed SAD for many years and speaks freely about her condition.[37]

Around 20% of Irish people are affected by SAD, according to a survey conducted in 2007. The survey also shows women are more likely to be affected by SAD than men.[38] An estimated 10% of the population in the Netherlands suffers from SAD.[39]

SAD and bipolar

Most people with SAD experience major depressive disorder, but as many as 20% may have or may go on to develop a bipolar disorder, a manic-depressive disorder. It is important to discriminate the improved mood associated with recovery from the winter depression and a manic episode because there are important treatment differences.[40] In these cases, persons with SAD may experience depression during the winter and hypomania in the summer.

See also

References

  1. ^ Seasonal Depression can Accompany Summer Sun. Ivry, Sara. The New York Times. Retrieved September 6, 2008
  2. ^ Lurie, Stephen J.; et al. (November 2006). "Seasonal Affective Disorder". American Family Physician (American Academy of Family Physicians) 74 (9): 1521–4. PMID 17111890. http://www.aafp.org/afp/20061101/1521.html. Retrieved 2009-07-26. 
  3. ^ U.S. National Library of Medicine
  4. ^ a b Seasonal Affective Disorder by Mayo Clinic
  5. ^ a b c d Modell, Jack; Rosenthal NE, Harriett AE, Krishen A, Asgharian A, Foster VJ, Metz A, Rockett CB, Wightman DS (2005). "Seasonal affective disorder and its prevention by anticipatory treatment with bupropion XL Biological Psychiatry". Biological psychiatry 58 (8): 658–667. doi:10.1016/j.biopsych.2005.07.021. PMID 16271314. 
  6. ^ a b Terman, M.; Terman, J.S. (2006). "Controlled Trial of Naturalistic Dawn Simulation and Negative Air Ionization for Seasonal Affective Disorder". American Journal of Psychiatry 163 (12): 2126–2133. doi:10.1176/appi.ajp.163.12.2126. 17151164. PMID 17151164. 
  7. ^ "Properly Timed Light, Melatonin Lift Winter Depression by Syncing Rhythms" (Science Update). National Institute of Mental Health. 2006-05-01. http://www.nimh.nih.gov/science-news/2006/properly-timed-light-melatonin-lift-winter-depression-by-syncing-rhythms.shtml. Retrieved 2009-08-30. 
  8. ^ Gabbard, Glen O. Treatment of Psychiatric Disorders (Third edition, Volume 2 ed.). Washington, DC: American Psychiatric Publishing. pp. 1296. 
  9. ^ a b c d e f Lam, RW; Levitt AJ, Levitan RD, Enns MW, Morehouse R, Michalak EE, Tam EM (2006). "The Can-SAD Study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder". American Journal of Psychiatry 163 (5): 805–812. doi:10.1176/appi.ajp.163.5.805. PMID 16648320. 
  10. ^ a b c d e Avery, D H; Eder DN, Bolte MA, Hellekson CJ, Dunner DL, Vitiello MV, Prinz PN (2001). "Dawn simulation and bright light in the treatment of SAD: a controlled study". Biological Psychiatry 50 (3): 205–216. doi:10.1016/S0006-3223(01)01200-8. PMID 11513820. 
  11. ^ Johansson, C; Smedh C, Partonen T, Pekkarinen P, Paunio T, Ekholm J, Peltonen L,Lichtermann D, Palmgren J, Adolfsson R, Schalling M (2001). "Seasonal affective disorder and serotonin-related polymorphisms". Neurobiology of Disease 8 (2): 351–357. doi:10.1006/nbdi.2000.0373. PMID 11300730. 
  12. ^ Johansson, C; Willeit M, Levitan R, Partonen T, Smedh C, Del Favero J, Bel Kacem S, Praschak-Rieder N,Neumeister A, Masellis M, Basile V, Zill P, Bondy B, Paunio T, Kasper S, Van Broeckhoven C, Nilsson LG,Lam R, Schalling M, Adolfsson R. (2003). "The serotonin transporter promoter repeat length polymorphism, seasonal affective disorder and seasonality". Psychological Medicine 33 (5): 785–792. doi:10.1017/S0033291703007372. PMID 12877393. 
  13. ^ Uz, T; Manev, H (2001). "Prolonged swim-test immobility of serotonin N-acetyltransferase (AANAT)-mutant mice". Journal of Pineal Research 30 (3): 166–170. doi:10.1034/j.1600-079X.2001.300305.x. PMID 11316327. 
  14. ^ a b Avery, D. H.; Kizer D, Bolte MA, Hellekson C (2001). "Bright light therapy of subsyndromal seasonal affective disorder in the workplace: morning vs. afternoon exposure". Acta Psychiatrica Scandinavica 103 (4): 267–274. doi:10.1034/j.1600-0447.2001.00078.x. PMID 11328240. 
  15. ^ Leppämäki, Sami; Haukka J, Lonnqvist J, Partonen T (2004). "Drop-out and mood improvement: a randomised controlled trial with light exposure and physical exercise". BMC Psychiatry 4 (22): 22. doi:10.1186/1471-244X-4-22. PMID 15306031. 
  16. ^ "Breakthroughs tips and trends: November 7th - Times Online". www.timesonline.co.uk. http://www.timesonline.co.uk/tol/life_and_style/health/article5106718.ece. Retrieved 2008-11-10. 
  17. ^ a b Nesse, Randolphe M; Williams, George C. Why We Get Sick (First ed.). New York: Vintage Books. pp. 290. 
  18. ^ Tuunainen, Arja; Kripke, Daniel F; Endo, Takuro; Tuunainen, Arja (2004). Light therapy for non-seasonal depression. doi:10.1002/14651858.CD004050.pub2. 
  19. ^ Moscovitch, A; Blashko CA, Eagles JM, Darcourt G, Thompson C, Kasper S, Lane RM (2004). "A placebo-controlled study of sertraline in the treatment of outpatients with seasonal affective disorder". Psychopharmacology 171 (4): 390–397. doi:10.1007/s00213-003-1594-8. PMID 14504682. 
  20. ^ Lam, Raymond W.; Anthony J. Levitt, Robert D. Levitan, et al. (May 2006). "The Can-SAD Study: A Randomized Controlled Trial of the Effectiveness of Light Therapy and Fluoxetine in Patients With Winter Seasonal Affective Disorder" (PDF, full text). Am J Psychiatry 163 (163): 805–812. doi:10.1176/appi.ajp.163.5.805. http://day-lights.com/light-therapy-news/downloads/can-sad-study-wp.pdf. Retrieved 2008-09-30. 
  21. ^ a b Terman, M.; Terman, J. S. (2006). "Controlled Trial of Naturalistic Dawn Simulation and Negative Air Ionization for Seasonal Affective Disorder". American Journal of Psychiatry 163: 2126. doi:10.1176/appi.ajp.163.12.2126. 
  22. ^ a b Terman, M. (1998). "A Controlled Trial of Timed Bright Light and Negative Air Ionization for Treatment of Winter Depression". Archives of General Psychiatry 55: 875. doi:10.1001/archpsyc.55.10.875 (inactive 2009-10-07). 
  23. ^ a b Terman, M; Terman, JS (1995). "Treatment of seasonal affective disorder with a high-output negative ionizer.". Journal of alternative and complementary medicine 1 (1): 87–92. doi:10.1089/acm.1995.1.87. PMID 9395604. 
  24. ^ Lundt, L (2004). "Modafinil treatment in patients with seasonal affective disorder/winter depression: an open-label pilot study". Journal of Affective Disorders 81: 173. doi:10.1016/S0165-0327(03)00162-9. 
  25. ^ Bhattacharjee, Y (2007). "Psychiatric research. Is internal timing key to mental health?". Science (New York, N.Y.) 317 (5844): 1488–90. doi:10.1126/science.317.5844.1488. PMID 17872420. http://www.ohsu.edu/ohsuedu/academic/som/images/Al-Lewy-Science.pdf. 
  26. ^ http://newfoundlandnews.blogspot.com/2008/01/sadness-seasonal-affective-disorder.html
  27. ^ http://www.nowfoods.com/M092051.htm
  28. ^ Lansdowne, AT; Provost, SC (1998). "Vitamin D3 enhances mood in healthy subjects during winter.". Psychopharmacology 135 (4): 319–23. doi:10.1007/s002130050517. PMID 9539254. 
  29. ^ Gloth Fm, 3rd; Alam, W; Hollis, B (1999). "Vitamin D vs broad spectrum phototherapy in the treatment of seasonal affective disorder.". The journal of nutrition, health & aging 3 (1): 5–7. PMID 10888476. 
  30. ^ http://www.sciencedaily.com/releases/2009/03/090317142847.htm
  31. ^ Jordanes, Getica, ed. Mommsen, Mon. Germanae historica, V, Berlin, 1882.
  32. ^ Magnusson, Andres; Axelsson, Johann; Karlsson, Mikael M.; Oskarsson, Högni (February 2000). "Lack of Seasonal Mood Change in the Icelandic Population: Results of a Cross-Sectional Study". Am J Psychiatry (American Psychiatric Association) 157 (2): 234–238. doi:10.1176/appi.ajp.157.2.234. PMID 10671392. http://ajp.psychiatryonline.org/cgi/content/full/157/2/234. Retrieved 2007-11-27. 
  33. ^ sson A, Magnú Axelsson J (1993). "The prevalence of seasonal affective disorder is low among descendants of Icelandic emigrants in Canada". Arch. Gen. Psychiatry 50 (12): 947–51. PMID 8250680. 
  34. ^ Cott, Jerry; Joseph R. Hibbeln (February 2001). "Lack of Seasonal Mood Change in Icelanders" (Letter to the Editor). Am J Psychiatry (American Psychiatric Association) 158 (158): 328. doi:10.1176/appi.ajp.158.2.328. http://ajp.psychiatryonline.org/cgi/content/full/158/2/328. Retrieved 2008-09-02. "Thus, high levels of fish consumption should be considered a potential etiology for the finding of a lack of seasonal affective disorder among the Icelandic population.". 
  35. ^ Horrocks, LA; Yeo, YK (1999). "Health benefits of docosahexaenoic acid (DHA)". Pharmacological research : the official journal of the Italian Pharmacological Society 40 (3): 211–25. doi:10.1006/phrs.1999.0495. PMID 10479465. 
  36. ^ Seasonal Affective Disorder and Latitude
  37. ^ [ http://www.andromedaspaceways.com/inter_0002.htm Andromeda Spaceways interview with Barbara Hambly, discusses SAD]
  38. ^ BreakingNews.ie - One in five suffers from SAD
  39. ^ Elsevier – Dark Days: Winter Depression (in Dutch, easy to translate to English with google translate (or anything like that)
  40. ^ "Depression" (PDF). Mood Disorders Society of Canada. http://www.mooddisorderscanada.ca/documents/Consumer%20and%20Family%20Support/Depression.pdf. Retrieved 2009-08-08. 

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