Hello, people… welcome back to the blog! Last week, we finished our two part series on phobias, and it seems everyone enjoyed it. I got a lot of great feedback on it, and people have been sharing their weird phobias with me even more than ever… I’ve really added to my list of doozies! This week, I wanted to talk about a topic I ran into recently, seasonal affective disorder, or SAD.
What is SAD? In the shrink bible, the DSM-5, it’s identified as a type of mood disorder. It’s not a standalone, but is specified as a major depressive disorder with a seasonal pattern, meaning that it happens every year at the same time, typically starting in fall or early winter and ending in spring or early summer. Because of this, some people call SAD the “winter blues,” but this is misleading, as there is a rarer form of seasonal depression known as “summer depression” that begins in late spring or early summer and ends in fall. And while the two types obviously share many symptoms, interestingly, their profiles are slightly different. More on that in a moment.
First, let’s talk statistics. In the United States, the percentage of the population affected by SAD is about 5%, but varies widely based on geographical location, from 1.4% of the population in Florida, to 9.9% in Alaska. This should give you a clue about one of the main factors associated with SAD, the amount of available sunlight. SAD may begin at any age, but it typically starts between the ages of 18 and 30, and as with other types of depression, SAD is much more common in women; they are three times more likely to be affected than men.
Calling SAD the “winter blues” makes it sound like no big deal, but people with SAD experience serious depression- the mood changes and symptoms are very similar to chronic depression- and these symptoms can have a major impact on their lives for 40% of the year, as symptoms usually occur during the fall and winter months and typically improve with the arrival of spring, with January and February being the most difficult months in the US. While temporary, SAD symptoms can be overwhelming, and in some cases, it can seriously interfere with daily functioning. Thankfully, it can be treated, and that’s why I decided to cover this topic. Recognizing the disorder is very important because it can cause such serious psychosocial impairment, but it’s not just important to recognize it… getting help is key, because acute treatment can be very effective, and maintenance treatment can actually prevent future episodes.
People with SAD experience mood changes and symptoms similar to depression, and these can vary from mild to severe. Everybody gets bummed out from time to time, those everyday feelings of sadness or fatigue brought on by life’s ups and downs- even during the holidays- but depression is a different animal.
Seasonal depression is marked by some specific symptoms, and these may include:
-Sleeping more than usual and still feeling drowsy and fatigued during the day
-Loss of interest in activities that once brought you joy
-Increase in purposeless physical activity, like pacing and hand wringing; an inability to sit still
-Slowed movements or speech, severe enough to be observable by others
-Feeling irritable and anxious
-Feeling guilty, worthless, hopeless, sad, tearful
-Desire to isolate, not wanting to see people
-Difficulty thinking, concentrating, or making decisions
-Increased appetite, overeating, and weight gain
-Cravings for carbohydrates
-Physical symptoms, such as headaches
-Thoughts of suicide or death
Clearly you don’t have to have every one of these to have SAD, and as with anything else, symptoms occur on a spectrum. Some people with SAD have mild symptoms and basically feel out of sorts or cranky, while others have symptoms that totally interfere with relationships and work. As I mentioned earlier, spring and summer SAD is much less common, but still occurs. The symptom profile is a little different; instead of people eating their way through it as a result of increased appetite, it’s difficult to get summer SAD people to eat at all, as they tend to have zero appetite. In my experience, it also seems to feature more agitation, almost manic type behavior.
What causes SAD? Like so many disorders, the cause isn’t completely understood, but we know that the body uses sunlight to regulate sleep, appetite, and mood. It’s believed that the decreased sunlight in the fall and winter months disrupt the body’s circadian rhythm. Lower light levels in winter disrupt the body clock, leading to depression and tiredness. As seasons change, people already naturally experience a shift in their biological internal clock that can cause them to be out of step with their daily schedule, so people may be more vulnerable during this time. The change in season, with shorter daylight hours, can lead to a biochemical imbalance in the brain, specifically in levels of serotonin and melatonin, two hormones that affect sleep and mood. SAD has been linked to this imbalance. There are risk factors involved as well. You’re more likely to develop SAD if you have an existing form of depression, or a relative with SAD or another form of depression. And Captain Obvious says that SAD is much more common in people living far from the equator where there are fewer daylight hours, so living somewhere where you expect months of darkness during the year isn’t the best plan if you have any of the risk factors.
The main feature of SAD is that your mood and behavior shift along with the calendar. So how do you know if you have it? If for the past 2 years, you:
-Had depression or mania that starts as well as ends during a specific season
-You didn’t feel these symptoms during your “normal” seasons
-Over your lifetime, you’ve had more seasons with depression or mania than without
I should note that sometimes it takes a while to diagnose SAD, because it can easily mimic so many other other conditions, like chronic fatigue syndrome, underactive thyroid, low blood sugar, viral illness, and/ or other mood disorders. If you suspect that you or a loved one may have it, the best course of action is to see a physician. There are online resources available as well, from the Center for Environmental Therapeutics, at cet.org. More on that at the end of this blog.
Clearly, you can’t stop the changing of the seasons, but there are some things you can do to combat SAD, including light therapy aka phototherapy, antidepressant medications, talk therapy aka cognitive behavioral therapy, or a combination of all three. Meds are usually brought in as adjuvants if light therapy is insufficient in reducing symptoms. Wellbutrin XL was the first drug approved specifically for SAD in the United States, and I’ve seen some success with it. Symptoms will generally improve on their own with the change of season, but it happens far more quickly with treatment. Treatment course differs depending on how severe your symptoms are, and of course, depending on whether you have another type of depression or bipolar disorder. For some people, simply increasing exposure to sunlight can help improve symptoms of SAD, and it’s recommended that people get outside early in the morning to get more natural light. If this is impossible because of the dark winter months, then phototherapy is key.
As I mentioned, light affects the biological clock in our brains that regulates our circadian rhythm, a physiological function that may induce mood changes when there’s less sunlight in winter. We know that natural or “full-spectrum” light can have an antidepressant effect. In phototherapy, you mimic that by sitting about 2 feet away from a light box, usually a 10,000-lux light box specifically, so that full spectrum bright light- about 20 times brighter than normal room lighting- shines directly upon you, but indirectly into your eyes. You do this for 15 minutes per day to start, and the times are increased as necessary with a max of 30 to 45 minutes a day, depending on your response. If using a weker lightbox, such as those that emit 2,500 lux, it will require much longer, about two hours of exposure per day.
Light therapy should be done in the early morning, upon waking, to maximize treatment response. Morning therapy also helps to specifically correct any sleep-wake cycle issues contributing to the symptoms. Please people, don’t look directly at the light source of any light box, to avoid possible damage to your eyes. I’ve heard of some practices that provide light boxes for patients with SAD. Again, the Center for Environmental Therapeutics has info on this. I’m sure you can also rent light boxes, and I know you can purchase them, but they’re expensive, and health insurance companies don’t usually cover them. But if you have SAD and live in a “dark” winter area, they can be worth their weight in gold.
Optimum dosing of light is crucial, since if done wrong it can produce no improvement, or partial improvement, and that can potentially lead to worsening of symptoms. I read some research that found that even a single, one hour light session can improve symptoms of depression in people with SAD. It varies; some people recover within days of using light therapy, most see some improvement within one or two weeks of beginning, but a few take longer. To maintain the benefits and prevent relapse, light treatment is usually continued through the winter, until you can be out in the sunshine again in the springtime. Because of the anticipated return of symptoms in late fall, I highly recommend that SAD patients begin phototherapy when fall first starts, even before feeling the effects of SAD. If the SAD symptoms don’t go away, your physician may increase light therapy sessions to twice daily. While side effects are minimal, be cautious if you have sensitive skin or a history of bipolar disorder. Common side effects of light therapy include headache, eyestrain, nausea, and agitation, but these effects are generally mild and transient, or disappear with reducing the dose of light.
Cognitive behavioral therapy or CBT can also be an effective treatment for SAD, particularly if it’s used in conjunction with light therapy and/ or medication. CBT involves identifying negative thought patterns that contribute to symptoms, and then replacing these thoughts with more positive ones. For many of my patients, I utilize all three modalities for treating SAD, as this has shown the most benefit.
… is worth a ton of cure in this case. So what can you do to avoid SAD?
Get out! Get as much natural sunlight as you can. Spend some time outside every day, even when it’s cloudy, as the effects of daylight still help. If it’s too cold out, let the sunshine in… open your blinds, and sit by a sunny window, even at work. If trees block the sunlight, trim them. I have a SAD patient that has her trees pruned way down in early fall so she can get as much light in the house as possible.
Eat a healthy, well-balanced diet. Our diets do more than provide us with energy, they also impact our mental health. A healthy diet rich in fruits and veggies and low in processed garbage can help curb feelings of depression by reducing inflammation in the body, which is a big risk factor for depression. Pass up all those sweet starchy “foods” in favor of lean proteins and veggies. This will help you have more energy, even if you’re craving carbs bigtime. If you recall the blog on Vitamin D, research has found that people with SAD often have low levels, so people with SAD are also often encouraged to increase their intake of Vitamin D through supplementation, in addition to diet and sunlight exposure.
Stay Active! Exercise is a great way to naturally combat the imbalance of brain neurotransmitters like serotonin, norepinephrine, and dopamine that can contribute to depression. When you exercise, your body produces endorphins, the mood boosting hormones that counteract serotonin and dopamine deficiencies that can bring you down. Exercise for 30 minutes a day, five times a week. That doesn’t have to mean you’re tied to the gym pumping iron all the time… Do something structured, but also pick an activity you enjoy and do it. Gardening, walking, dancing, and even playing with your kids can all be good forms of exercise.
Stay Connected! Social connections can be a great defense against depression. Whether you talk on the phone, video chat, or better yet, meet in person, keep in regular contact with friends and family for a healthy and happy mind. Experiencing depression of any kind isn’t a sign of weakness and shouldn’t be dealt with alone. Social support is very important, so stay involved with your social circle and regular activities. If you’re experiencing symptoms of depression that keep you in, seek help. Ask your physician what treatment options are available.
When should you call your physician? If you feel depressed, fatigued, and cranky at the same time each year, if it seems to be seasonal in nature, you may have a form of SAD. Talk openly with your physician, and follow their recommendations for lifestyle changes and treatment.
The Center for Environmental Therapeutics, CET, is a non-profit organization that provides information and educational materials about SAD, along with free, downloadable self-assessment questionnaires and interpretation guides, to help you determine if you should seek professional advice. All of that can be found on their website, cet.org.
I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon.
Thank you and be well people!