CLINICAL DIFFERENCES IN SEASONAL AND NON- SEASONAL DEPRESSION

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1 ORIGINAL ARTICLES CLINICAL DIFFERENCES IN SEASONAL AND NON- SEASONAL DEPRESSION Radu Romosan 1, Tiberiu Mircea 1, Felicia Romosan 1,2,3, Monica Ienciu 1,2, Lucian Ile 2,3, Cristina Bredicean 1,2,3, Ion Papava 1,2,3, M. Milin 4 REZUMAT Obiective: Compararea profilului simptomatologic al episoadelor depresive sezoniere şi non-sezoniere. Material si metode: Au fost selecţionaţi 15 pacienţi cu episoade depresive sezoniere şi 22 de pacienţi cu episoade depresive non-sezoniere, aparţinând categoriilor diagnostice de tulburare afectivă bipolară tip I şi tip II şi tulburare depresivă majoră, după criteriile DSM-IV TR, internaţi în Clinica de Psihiatrie Timişoara în perioada Evaluarea a fost retrospectivă, realizată pe baza documentaţiei medicale. Ca instrumente de lucru s-au folosit scala de evaluare a depresiei Hamilton (HDRS), înregistrarea greutăţii, calitatea somnului, apetitul alimentar, documentate în foaia de observaţie. Rezultate: La grupul de pacienţi cu episoade depresive sezoniere au fost găsite mai frecvent simptome vegetative atipice cu hipersomnie, creştere ponderală şi a apetitului alimentar, iar la grupul de pacienţi cu episoade depresive non-sezoniere simptome vegetative tipice, cu insomnie, scăderea apetitului alimentar şi a greutăţii corporale. Concluzii: Episoadele depresive sezoniere au fost mai frecvente la pacienţii cu diagnosticul de depresie majoră recurentă şi la pacienţii cu tulburare afectivă bipolară de tip II. Simptomele vegetative tipice au fost prezente preponderent la lotul de pacienţi cu depresie non-sezonieră, cele atipice fiind mai frecvente la lotul de pacienţi cu depresie de model sezonier. Cuvinte cheie: tulburare afectivă sezonieră, tulburare depresivă majoră, tulburare afectivă bipolară ABSTRACT Objectives: Comparison of the symptomatic profile of seasonal and non-seasonal depressive episodes. Material and methods: Fifteen in-patients with seasonal depressive episodes and 22 in-patients with non-seasonal depressive episodes, admitted in the Timisoara Psychiatric Clinic between 2007 and 2011 were selected in this study. The diagnoses of the patients were bipolar affective disorder type I, II or major depressive disorder, according to DSM-IV-TR criteria. Retrospective evaluation was based on medical documentation. Methods used were the Hamilton Depression Rating Scale (HDRS), recording of weight, quality of sleep, appetite and the patient s chart. Results: In the group of patients with seasonal depressive episodes we more frequently found atypical vegetative symptoms such as hypersomnia, increased appetite and weight gain, and in the group of patients with non-seasonal depressive episodes we found typical vegetative symptoms, with insomnia, decreased appetite and weight loss. Conclusions: Seasonal depressive episodes were more common in patients diagnosed with recurrent major depression and type II bipolar affective disorder. Typical vegetative symptoms were mainly present in the group of patients with non-seasonal depression, whilst atypical symptoms were more frequent in the group of patients with a seasonal depressive pattern. Key Words: seasonal affective disorder, major depressive disorder, bipolar affective disorder INTRODUCTION During the course of evolution, most organisms have adapted to the geophysical cycle of day and night and their modulation across the length of the year. 1 Department of Psychiatry, Victor Babes University of Medicine and Pharmacy, Timisoara, 2 Eduard Pamfil Psychiatric Clinic, Timisoara, 3 Mara Institute, Timisoara, 4 Clinical Municipal Hospital, Timisoara Correspondence to: Dr. Radu-Stefan Romosan, Department of Psychiatry, Victor Babes University of Medicine and Pharmacy, 2A Eftimie Murgu Sq., Timisoara, Romania, Tel Received for publication: Oct. 11, Revised: Nov. 14, Man also has a physiological and behavioral circadian rhythm, led by the biological clock, which depends on the time schedule of seasonal changes in day length. Seasonal vulnerability is a feature of several psychological disorders and this type of environmental influence has been studied for several centuries, especially regarding depression. Longitudinal studies of patients suffering from recurrent major depressive episodes have shown the existence of a particular relationship with the seasonal changes in temperate regions. Seasonal depression was first described by Rosenthal and is characterized by recurrent depressive episodes whose onset is during winter-time and which are responsive to light-therapy. 1 Wehr later described the summer depression that was supposed 216 TMJ 1108, Vol. 61, No. 3-4

2 to be responsive to external temperature handling. 2 Community epidemiological studies indicate a lifetime prevalence for seasonal affective disorder estimated between 1.4 and 9.7% in North America and between 1.3 and 3.0 % in Europe. 3-8 Seasonal pattern can be applied, according to the diagnostic criteria of DSM-IV-TR to major depressive episodes in BD I, BD II (Bipolar Affective Disorder type I, II) or MDD (Major Depressive Disorder). 9 A seasonal pattern in depressive episodes is present when we can detect a regular temporal relationship between the onset of major depressive episodes and a particular time of the year (e.g. the onset of a major depressive episode during autumn or winter) for at least two years in a row without psycho-social stressors in relation to season. Also, a full remission (or change from depression to mania or hypomania) must occur in the same season or time of the year (e.g. a remission of depressive symptoms during spring). The number of seasonal major depressive episodes must substantially exceed non-seasonal major depressive episodes that occurred during the lifetime of the individual. Characteristic of patients with seasonal depression, in addition to the criteria of major depression is the presence of a higher frequency of atypical symptoms such as increased duration of sleep, increased appetite and weight gain. 1,2 The purpose of this study was to identify cases with seasonal depressive episodes and to compare the profile of symptoms between seasonal and nonseasonal depressive episodes. MATERIALS AND METHOD Subjects Fifteen in-patients, with seasonal depressive episodes and 22 in-patients with non-seasonal depressive episodes, admitted in the Timisoara Psychiatric Clinic between 2007 and 2011, aged 18 to 65 were selected in this study. The diagnoses of the patients were BD I, II or MDD, according to DSM- IV-TR criteria. 9 The inclusion criteria for cases with seasonal depression were: a history of at least two main episodes with onset during the same time of the year, two years consecutively and remission not later than six months after the onset of symptoms. The inclusion criteria for patients with non-seasonal depressive episodes were: a history of at least two main depressive episodes, spaced at least one year apart. Patients with an age below 18 or over 65 years, cases of abuse or addiction to alcohol or drugs and those with a limited capacity to give valid consent were excluded from the study. There were nine female subjects in the seasonal group and 12 in the non-seasonal group. Patients received information regarding study design and were asked to give an informed consent to participate in the study. As the study interferes very little with the follow-up treatment, all subjects who were invited agreed to participate. At the time of enrollment all subjects were in a depressive episode. Anamnestic data was evaluated retrospectively via the observation sheet and direct interview. Measurements Several clinical and demographical variables have been comparatively analyzed (both in term of numbers and percentages) such as : sex, age at onset, duration of the depressive episode, duration of the disorder, evaluation of depression severity using the HDRS (Hamilton Depression Rating Scale) and vegetative symptoms (weight, appetite, sleep quality). Statistical analysis was performed using SPSS v and the graphical charts were made with Microsoft Excel The results for continuous variables were expressed as mean values and standard deviations, while those for categorical data were expressed as counts and percentages. Depending on the type of the variables, either the t-test for independent samples or the Pearson chi-square test was applied to test the statistical significance of the differences observed between the two groups, i.e. with seasonal or nonseasonal depression. RESULTS The distribution of cases in the two distinct groups (seasonal and non-seasonal) can be observed in Figure 1. In the group with seasonal depressive episodes, 11 subjects (73.33 %) had been diagnosed with MDD, three (20 %) with BD II and one (6.67 %) with BD I. In the non-seasonal depression group 13 subjects (59.1 %) had been diagnosed with MDD, six (27.27%) with BD II and three (13.63 %) with BD I. Table 1 presents demographic and clinical data of patients with seasonal and non-seasonal depressive episodes. Mean age at onset stood at 26.60±4.45 years in the seasonal group, whilst in the non-seasonal group it was 29.82±5.16. Mean disorder duration (years) and mean episode duration (months) were 16.53±10.83 / 4.60±2.32 in the seasonal group and 16.64±6.81 / 4.00±1.98 in the non-seasonal group. Mean HDRS- 17 scores in the seasonal group were 22.20±4.87 and 20.41±4.13 in the non-seasonal group. Radu Romosan et al 217

3 Table 1. Demographical and clinical characteristics of the two patient groups Seasonal (n=15) Non-seasonal (n=22) Comparison between the two groups (seasonal vs non-seasonal) Male/Female 6/9 10/12 p=0.742 (Pearson chi-square test) BP/MDD 4/11 9/13 p=0.373(pearson chi-square test) Age in years (m s) p=0.375 (t-test); p=0.083 (Levene s test for variances) Age at onset (m s) p=0.057 (t-test); p=0.529 (Levene s test for variances) Disorder duration (m s) p=0.974 (t-test); p=0.024* (Levene s test for variances) Episode duration (m s) p=0.404 (t-test); p=0.452 (Levene s test for variances) HDRS-17 score (m s) p=0.236 (t-test); p=0.497 (Levene s test for variances) Figure 1. Distribution of the distinct diagnoses in the two patient groups (%). The subjects in the seasonal group were more likely to exhibit atypical vegetative symptoms: increased appetite (80% vs %, p=0.009), weight gain (73.34% vs %, p=0.006), hypersomnia (86.67% vs. 40.9%, p=0.005). Patients with nonseasonal depressive episodes were more likely to exhibit frequent typical vegetative symptoms: loss of appetite (59.1% vs. 6.67%, p=0.001), weight loss (59.1% vs. 6.67%, p=0.001), insomnia (59.1% vs. 6.67%, p=0.001). (Fig. 2, Table 2) DISCUSSIONS No statistically significant differences were found between the two groups regarding most demographical and clinical characteristics. Table 2. The presence of symptoms (both typical and atypical) in seasonal and non-seasonal depression. Highly significant statistical differences (marked with **) were found for all the six symptoms considered. Figure 2. Typical and atypical symptoms in seasonal and non-seasonal depression. There were no significant statistical differences regarding disorder duration within the two groups, still, the high variability (p=0.024) in the seasonal group may have affected this result. In the future, a comparison of more homogenous samples would yield better results. There was a marginally significant statistic difference regarding age at onset between the two groups, with a higher mean value in the nonseasonal group. Highly significant statistical differences were found for all the six symptoms considered (three typical and three atypical depressive symptoms). Our results are consistent with other studies that have shown increased prevalence of atypical vegetative symptoms in patients with seasonal depressive episodes. 1,10-14 According to the literature, data regarding the prevalence of seasonal depression differs, some authors reported a higher prevalence for seasonal depression in bipolar patients and other authors reported an Seasonal (n=15) Non-seasonal (n=22) p-values (Pearson chi-square test) Loss of appetite 1 (7%) 13(59%) 0.001** Increased-appetite 12 (80%) 8 (36%) 0.009** Weight loss 1 (7%) 13(59%) 0.001** Weight gain 11(73%) 6 (27%) 0.006** Insomnia 1 (7%) 13(59%) 0.001** Hypersomnia 13 (87%) 9 (41%) 0.005** 218 TMJ 1108, Vol. 61, No. 3-4

4 increased prevalence for seasonal depression in patients with MDD. In our study, subjects with bipolar disorder type I and II tend to be non-seasonal Other studies have showed a higher prevalence of seasonal and non-seasonal depression in women Evaluating a larger nation-wide sample of seasonal and non-seasonal subjects in the future study might confirm the findings of other studies. The limits of this preliminary study are the relatively small number of cases investigated and the retrospective evaluation method which allows only an indirect assessment of seasonal patterns. A larger number of cases (nation-wide), a prospective study design, the inclusion of subjects with schizo-affective disorder or other mood disorders and a wider set of data could provide additional information on the effect of seasonal affective disorder. Detecting the evolutionary model of seasonal affective disorder in patients may be important in terms of differentiated therapeutic approach using lighttherapy in cases with seasonal depression. 1,6,16,22,27-31 CONCLUSIONS The evolutionary pattern of seasonal depression was found more frequently in patients with recurrent major depressive disorder and in those with bipolar affective disorder type II. Typical vegetative symptoms were mainly present in the group of patients with non-seasonal depression, whilst atypical symptoms were more frequent in the group of patients with a seasonal depressive pattern. These results may help facilitate the preparedness of mental health services at different times during the year and possibly a different therapeutic approach. ACKNOWLEDGEMENT During the research described in this paper, the first author, Radu Romosan, benefitted by a grant from the PhD programme POSDRU/88/1.5/S/ REFERENCES 1. Rosenthal NE, Sack DA, Gillin JC et al. 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