DOC ON CALL

By Maninder Singh, MD
Week of February 10, 2008

Seasonal Affective Disorder

Why do some people feel blue during the winter months but are fine for the rest of the year? Is it part of the evolutionary change occurring during the winter months ,as the days get shorter and the nights gets longer ,where a lot of animals go into the hibernating mode ,eating more and sleeping more, feeling less energetic ;or is it something more serious? Why do some people feel that they are depressed during rainy days and feel better on sunny days? A lot of these people are told that it is “all in your head” and most people feel they should be able to tough it out. Well the good news is that there is actually a disorder called the “Seasonal affective disorder“ and it is treatable so one does not have to hate the thought of winter coming every year. It is not diagnosed in official book of psychiatric diagnosis however more and more clinicians are aware of it and diagnose it as a form of depression.

Signs and Symptoms

Seasonal affective disorder is a cyclic, seasonal condition. This means that signs and symptoms usually come back and go away at the same times every year. Usually, seasonal affective disorder symptoms appear during late fall or early winter and go away during the warmer, sunnier days of spring and summer. But some people have the opposite pattern, developing seasonal affective disorder with the onset of spring or summer. In either case, problems may start out mild and become more severe as the season progresses. Fall and winter SAD (winter depression)

Symptoms of winter-onset seasonal affective disorder include:

Depression
Hopelessness
Anxiety
Loss of energy
Social withdrawal
Oversleeping
Loss of interest in activities you once enjoyed
Appetite changes, especially a craving for foods high in carbohydrates
Weight gain
Difficulty concentrating and processing information
Spring and summer SAD (summer depression)

Symptoms of summer-onset seasonal affective disorder include:

Anxiety
Insomnia
Irritability
Agitation
Weight loss
Poor appetite
Increased sex drive
Reverse SAD

In rare cases, people with seasonal affective disorder don't have depression-like symptoms. Instead, they have symptoms of mania or hypomania, a less intense form of mania, during the summer. This is sometimes called reverse SAD. Symptoms of reverse SAD include:

- Persistently elevated mood
- Increased social activity
- Hyperactivity
- Unbridled enthusiasm out of proportion to the situation

Causes

The specific cause of seasonal affective disorder remains unknown. It's likely, as with many mental health conditions, that genetics, age and perhaps most importantly, body's natural chemical makeup all play a role in developing seasonal affective disorder. Some of the theories behind the causation of SAD are: Circadian rhythm. Some researchers suspect that the reduced level of sunlight in fall and winter may disrupt the circadian rhythm in certain people. The circadian rhythm is a physiological process that helps regulate your body's internal clock — letting you know when to sleep or wake. Disruption of this natural body clock may cause depression; Melatonin- SAD etiology may be tied to melatonin, a sleep-related hormone that, in turn, has been linked to depression. The body's production of melatonin usually increases during the long nights of winter.

Serotonin-other research suggests that a lack of serotonin, a natural brain chemical (neurotransmitter) that affects mood, may play a role. Reduced sunlight can cause a drop in serotonin, perhaps leading to depression.

Risk factors

Although seasonal affective disorder commonly begins in young adulthood, it's uncommon in people younger than 20. Some studies show that it's diagnosed more often in women, but that men may have more severe symptoms. There is no good data about how common seasonal affective disorder is and who is most likely to develop the condition .Some evidence shows that factors that may increase the risk of developing seasonal affective disorder include:

Northern locations- SAD is more common among people who live in higher latitudes — or farther from the equator.

Family history- Some studies have shown that people with SAD are more likely to have family members with the condition.

When to seek medical advice

Most people experience some days when they feel down or feel blue .However if you feel down for days at a time and you can't seem to get motivated to do activities you normally enjoy, see your doctor. This is particularly important if you notice that your sleep patterns and appetite have changed — and certainly if you feel hopeless, think about suicide, or find yourself turning to alcohol or other illicit substances for comfort or relaxation..

Even with a thorough evaluation, it can sometimes be difficult for your doctor or mental health provider to diagnose seasonal affective disorder because other types of depression or mental health conditions may mimic SAD. Diagnosing seasonal affective disorder depends on whether you've experienced depression and other symptoms for at least two consecutive years, during the same season. The periods of depression have been followed by periods without depression. There are no other explanations for the changes in your mood or behavior. Seasonal affective disorder can have serious complications if left untreated. These complications may include:

- Suicidal thoughts or behavior - Social withdrawal - School or work problems - Substance abuse

Treatment

Like depression, it's often possible to successfully manage seasonal affective disorder. In milder cases, you may be able to take measures on your own, such as spending more time outdoors or sitting closer to bright windows while at home or in the office. Other treatments for seasonal affective disorder include:

Light therapy

Because increased sunlight improves symptoms, light therapy is often a main treatment for many people with seasonal affective disorder. However, light therapy hasn't been officially approved as a treatment by the Food and Drug Administration because of a lack of definitive evidence about its effectiveness in clinical trials. Before you purchase a light therapy box or consider light therapy, consult your doctor or mental health provider to make sure it's right for you. Light therapy mimics outdoor light and causes a biochemical change in your brain that lifts your mood, relieving symptoms of seasonal affective disorder. In light therapy, you sit a few feet from a specialized light therapy box so that you're exposed to very bright light. Light therapy is generally easy to use and has relatively few side effects.

Medications

Some people with seasonal affective disorder benefit from treatment with antidepressants or other psychiatric medications, especially if symptoms are severe. The Food and Drug Administration has approved bupropion extended release tablets (Wellbutrin XL) for the prevention of depressive episodes in people with a history of seasonal affective disorder. Other antidepressants commonly used to treat seasonal affective disorder include paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac) and venlafaxine (Effexor). Your doctor may recommend starting treatment with an antidepressant before your symptoms typically begin each year. He or she may also recommend that you continue to take antidepressant medication beyond the time your symptoms normally go away. This strategy can help prevent worsening of symptoms. Keep in mind that it may take several weeks to notice full benefits from an antidepressant. In addition, you may have to try several different medications before you find one that works well and has the fewest side effects. Like other medications, all antidepressants pose the risk of side effects and some have health precautions that you and your doctor must discuss.

Psychotherapy

Psychotherapy is another option to treat seasonal affective disorder. Although seasonal affective disorder is thought to be related to biochemical processes, your mood and behavior also can contribute to symptoms. Psychotherapy can help you identify and change negative thoughts and behaviors that may be making you feel worse. You can also learn healthy ways to cope with seasonal affective disorder and manage stress.

Prevention

There's no known way to prevent the development of seasonal affective disorder. However, if you take steps early on to manage symptoms, you may be able to prevent them from getting worse over time. Some people find it helpful to start treatment before symptoms would normally start in the fall or winter, and then continue treatment past the time symptoms would normally go away. If you can get control of your symptoms before they begin, you may be able to head off serious changes in mood, appetite and behavior that can disrupt your daily life.

Other helpful skills to help you cope with SAD

- Stick to your treatment plan. Take medications as directed and attend therapy appointments as scheduled.
- Let there be light. Make your home sunnier and brighter. Open blinds, add skylights and trim tree branches that block sunlight.
- Get out. Get outdoors on sunny days, even during winter. Take a long walk, eat lunch at a nearby park, or simply sit peacefully on a bench and soak up the sun.
- Exercise regularly. Physical exercise helps relieve stress and anxiety, both of which can increase SAD symptoms. Being more fit can make you feel better about yourself, too, which can lift your mood.
- Take care of yourself. Get enough rest, eat a balanced diet and take time to relax. Don't turn to alcohol or illicit drugs for relief.
- Practice stress management. Learn how to better manage stress. Unmanaged stress can lead to depression, overeating, or other unhealthy thoughts and behaviors.
- Socialize. Stay connected with people you enjoy being around. They can offer support, a shoulder to cry on or a joke to give you a little boost.
- Take a trip. If possible, take winter vacations in sunny, warm locations if you have winter SAD or cooler locations if you have summer SAD.

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