OT: Seasonal Affective Disorder

Seasonal Affective Disorder

If you notice periods of depression that seem to accompany seasonal changes during the year, you may suffer from seasonal affective disorder (SAD). This condition is characterized by recurrent episodes of depression – usually in late fall and winter – alternating with periods of normal or high mood the rest of the year.

Most people with SAD are women whose illness typically begins in their twenties, although men also report SAD of similar severity and have increasingly sought treatment. SAD can also occur in children and adolescents, in which case the syndrome is first suspected by parents and teachers. Many people with SAD report at least one close relative with a psychiatric condition, most frequently a severe depressive disorder (55 percent) or alcohol abuse (34 percent).

What are the patterns of SAD?

Symptoms of winter SAD usually begin in October or November and subside in March or April. Some patients begin to slump as early as August, while others remain well until January. Regardless of the time of onset, most patients don’t feel fully back to normal until early May. Depressions are usually mild to moderate, but they can be severe. Very few patients with SAD have required hospitalization, and even fewer have been treated with electroconvulsive therapy.

The usual characteristics of recurrent winter depression include oversleeping, daytime fatigue, carbohydrate craving and weight gain, although a patient does not necessarily show these symptoms. Additionally, there are the usual features of depression, especially decreased sexual interest, lethargy, hopelessness, suicidal thoughts, lack of interest in normal activities, and social withdrawal.

Light therapy, described below, is now considered the first-line treatment intervention, and if properly dosed can produce relief within days. Antidepressants may also help, and if necessary can be used in conjunction with light.

In about 1/10^th of cases, annual relapse occurs in the summer rather than winter, possibly in response to high heat and humidity. During that period, the depression is more likely to be characterized by insomnia, decreased appetite, weight loss, and agitation or anxiety. Patients with such "reverse SAD" often find relief with summer trips to cooler climates in the north. Generally, normal air conditioning is not sufficient to relieve this depression, and an antidepressant may be needed.

In still fewer cases, a patient may experience both winter and summer depressions, while feeling fine each fall and spring, around the equinoxes.

The most common characteristic of people with winter SAD is their reaction to changes in environmental light. Patients living at different latitudes note that their winter depressions are longer and more profound the farther north they live. Patients with SAD also report that their depression worsens or reappears whenever the weather is overcast at any time of the year, or if their indoor lighting is decreased.

SAD is often misdiagnosed as hypothyroidism, hypoglycemia, infectious mononucleosis, and other viral infections.

How is winter SAD treated with light?

Bright white fluorescent light has been shown to reverse the winter depressive symptoms of SAD. Early studies used expensive "full-spectrum" bulbs, but these are not especially advantageous. Bulbs with color temperatures between 3000 and 6500 degrees Kelvin all have been shown to be effective. The lower color temperatures produce "softer" white light with less visual glare, while the higher color temperatures produce a "colder" skylight hue. The lamps are encased in a box with a diffusing lens, which also filters out ultraviolet radiation. The box sits on a tabletop, preferably on a stand that raises it to eye level and above. Such an arrangement further reduces glare sensations at high intensity, and preferentially illuminates the lower half of the retina, which is rich in photoreceptors that are thought to mediate the antidepressant response. Studies show between 50% and 80% of users showing essentially complete remission of symptoms, although the treatment needs to continue throughout the difficult season in order to maintain this benefit.

There are three major dosing dimensions of light therapy, and optimum effect requires that the dose be individualized, just as for medications.

• Light intensity. The treatment uses an artificial equivalent of early morning full daylight (2500 to 10,000 lux), higher than projected by normal home light fixtures (50 to 300 lux). A light box should be capable of delivering 10,000 lux at eye level, which allows downward adjustments if necessary.
• Light duration. Daily sessions of 20 to 60 minutes may be needed. Since light intensity and duration interact, longer sessions will be needed at lower intensities. At 10,000 lux – the current standard – 30-minute sessions are most typical.
• Time of Day of exposure. The antidepressant effect, many investigators think, is mediated by light’s action on the internal circadian rhythm clock. Most patients with winter depression benefit by resetting this clock earlier, which is achieved specifically with morning light exposure. Since different people have different clock phases (early types, neutral types, late types), the optimum time of light exposure can differ greatly. The Center for Environmental Therapeutics, a professional nonprofit agency, offers an on-line questionnaire on its website, www.cet.org, which can be used to calculate a recommended treatment time individually, which is then adjusted depending on response. Long sleepers may need to wake up earlier for best effect, while short sleepers can maintain their habitual sleep-wake schedule.

Side effects of light therapy are uncommon. Some patients complain of irritability, eyestrain, headaches, or nausea. Those who have histories of hypomania in spring or summer are at risk for switching states under light therapy, in which case light dose needs to be reduced. There is no evidence for long-term adverse effects, however, and disturbances experienced during the first few exposures often disappear spontaneously. As an important precaution, patients with Bipolar I disorder – who are at risk for switching into full-blown manic episodes – need to be on a mood-stabilizing drug while using light therapy.

What should I do if I think I have SAD?

If your symptoms are mild – that is, if they don't interfere too much with your daily living, you may want to try light therapy as described above or experiment with adjusting the light in your surroundings with bright lamps and scheduling more time outdoors in winter.

If your depressive symptoms are severe enough to significantly affect your daily living, consult a mental health professional qualified to treat SAD. He or she can help you find the most appropriate treatment for you. To help you decide whether a clinical consultation is necessary, you can use the feedback on the Personalized Inventory for Depression and SAD at www.cet.org.

 

Reviewed by Michael Terman, Ph.D., Director, Winter Depression Program, New York State Psychiatric Institute at Columbia University Medical Center. New York City (February, 2004).

Permission is granted for this fact sheet to be reproduced, but it must include the NAMI name, logo, and contact information.

 

I have struggled with SAD since the early 80s - it can get real scary.  Most people like to give me a LOT of grief because I am not a "happy-happy" Christmas kinda gal.  I had my life turned up-side-down for 6 weeks between Turkey Day and January 3rd and if I don't want to be all touchy-feely Xmasy, I don't have to!  I don't hide in bed for 3 days (like I used to), I have learned to deal with issues and how to overcome the "feelings" I have.  It's a long hard journey, harder than this current one we are on.  It can also be very overwhelming--BTDT bought the Tshirt!  In my opinion, this concept could be attributing to some of the things currently going on on the TMB.  It's very hard to stay happy and positive when you are living with SAD.  My 2cents worth, that's all!

Thanks for posting this -- it's a good reminder of the things that I have to do for ME! 
Hope you have a great holiday (if nuttin else we have 4 days off, huh???)

Hugs, Mari

Mari,

I posted it because yesterday was the 11th annual National Survivors of Suicide Day and we got to discussing this topic on my post.

I felt like it was something that needed to be posted so that others who are going through it could know what it was and know that they were not alone.

I do not have this, but I have Bipolar I (which is my own little hell) , but I am going through depression now due to the holidays and it is really hard.

I am in therapy and on meds and am managing my symptoms well, but I know that there are those who out of shame or fear or not being educated on the subject choose to do nothing about it.

Maybe this post will generate a lot of good conversations.

I don't work so I am off everyday.

I hope you have an absolutely fabulous holiday as well.

Teena thanks for sharing this article.  I have suffered from SAD since my early 20s.  I really was not sure what was going on but every year around Halloween and until spring came around I was very emotional and would cry at the drop of a hat. 

I couldn't identify why and when someone asked why and I had no answer they didn't understand.  SAD affects so many people, many aren't aware of it and I'm sure like me thought they were going crazy.  How do you answer others when they say "What is the matter?" and your reply is "I don't know". 

I do not like the holiday season, I don't find lots of joy in it.  Sometimes it's a matter of faking it for my children because it is an exciting, happy time for them. 

Again thanks for sharing this article.

Hugs,

You are so welcome.

I posted it due to a post I posted yesterday and we got to talking on this subject yesterday.

I am sorry that you suffer with this.

I do not, but I do have Bipolar I and the holidays for me are the worse when it comes to depression and I have been battling it here lately so I wanted to open a dialogue on here as I knew I was not alone.

I credit my meds and my therapist for me being able to cope, but I am curious to hear how others cope.

Teena, I take Cymbalta for depression and try to surround myself with fun things to keep me occupied.  I do find the dreary weather that makes me stay inside just compounds the emotions.

I had a hysterectomy last Monday and I have been on a rollercoaster the past couple of days.  From happy to sad to crying and back.  I have a followup with my OB/GYN tomorrow and will let her know everything going on.  This is no fun, those that do not understand depression or have never experienced are very fortunate.

WOW.

You are just going at it at every angle.

Sorry I have been offline lately due to illness and depression and had no clue of your surgery last week.

Glad you came through your hysterectomy ok.

Sorry about the emotional turmoil though, but I know what you mean about going back and forth with crying and filip flopping emotionally.

I take Lamictal, Seroquel, Zoloft, Xanax, various sleep medications for my Bipolar I and it has helped me out tons.

I also try to get out and stay busy.

Since I do not work I find staying in the house causes me to get more depressed.

I can't wait til school starts.

I also think all this rain and dooms day like weather has affected me as well.

I also feel that those who have never experienced depression are hella fortunate, but I feel they need to learn about it so they know the signs and how to cope and treat us humanely that are going through depression.

I get so tired of family or friends who have no clue, but mean well telling me to just get over it or cheer up or my fav "It's all in my head"

No **** Sherlock!!!

I would get over it if it were as easy as they think it is.

I by all means am no negative Nancy and that is why when I am depressed I isolate because I get tired of the get over it or cheer up comments.

I also belong to a few support groups for others who go through depression and Bipolar like me so that, my meds, and therapy provide me solace during these times.

Glad we got to talk about this subject.

I hope others will be able to read this and see that they indeed are not alone.

Take care.

I hope you have an absolutely fabulous day.

Dana,
How true that those who have not lived with depression (either personal knowledge or a familial connection) do not understand it.  They'll be the first ones who tell you to "snap out of it."  I've watched myself and others spiral out of control this time of year...pretty much of a daily struggle. I'm just thinking how fortunate I am that I have gotten off my anti-depressants since surgery.  I hope it lasts! 

Hugs, M

Although I don't suffer from chronic depression I do definitely get Seasonal Affective Disorder every year. I bought a SAD light therapy machine and it has worked great!! I've also started taking Vitamin D supplements (You need to take D3,) melatonin and magnesium. I have found all of these things have really helped me!!  Thanks for the great article! People need to know about this and also how easy it can be to resolve!!

Cheers
Lexy