What is Seasonal Affective Disorder?

Some people suffer from symptoms of depression during the winter months, with symptoms subsiding during the spring and summer months. This may be a sign of Seasonal Affective Disorder (SAD). SAD is a mood disorder associated with depressive episodes and related to seasonal variations of available light. The clinical term for Winter Blues is subsyndromal SAD. It is less severe than clinical SAD and can generally be dealt with without counseling or anti-depressant therapy.

 

Throughout the centuries, poets have described a sense of sadness, loss and lethargy which can accompany the shortening days of fall and winter. Many cultures and religions have winter festivals associated with candles or fire. Many of us notice tiredness, a bit of weight gain, difficulty getting out of bed and bouts of "the Winter Blues" as fall turns to winter. The sunlight has affected the seasonal activities of animals (i.e., reproductive cycles and hibernation), and SAD may be an effect of this seasonal light variation in humans. As seasons change, there is a shift in our "biological internal clocks" or circadian rhythm, due partly to these changes in sunlight patterns. This can cause our biological clocks to be out of "step" with our daily schedules.

The most difficult months for SAD sufferers are January and February, and younger people and women are at higher risk. Some people experience an exaggerated form of these symptoms. Their depression and lack of energy become debilitating. Work and relationships suffer. SAD may affect over 10 million Americans while the milder, "Winter Blues" may affect a larger number of individuals.

 

The symptoms of SAD recur regularly each Winter, from September to November and continuing until March or April, and a diagnosis can be made after three or more consecutive years of symptoms. About 70-80% of those with SAD are women. SAD may begin at any age but the main age of onset is between 18 and 30 years with the most common age of onset being in one's thirties. However, SAD is not rare in children. It occurs throughout the northern and southern hemispheres but is extremely rare in those living within 30 degrees of the Equator, where daylight hours are long, constant and extremely bright.

 

There seems to be interplay between an individual's innate vulnerability and her degree of light exposure. For instance, one person might feel fine all year in Maryland but develop SAD when she moves to Toronto. Another individual may be symptomatic in Baltimore, but have few symptoms in Miami.

 

Some individuals who work long hours inside office buildings with few windows may experience symptoms all year round. Some very sensitive individuals may note changes in mood during long stretches of cloudy weather. Theories about how light affects mood and sleep

 

In 1984, a psychiatrist at NIMH, Norman Rosenthal, published a paper on the use of bright light therapy in patients with this disorder. Since then, a large number of well-designed studies have confirmed and refined these findings. Researchers are still investigating mode by which bright light can lift depression or reset a sleep cycle

 

Symptoms Include:

 

1. regularly occurring symptoms of depression (excessive eating and sleeping, weight gain) during the fall or winter months.

2. full remission from depression occur in the spring and summer months.

3. symptoms have occurred in the past two years, with no non-seasonal depression episodes.

4. seasonal episodes substantially out-number non-seasonal depression episodes.

5. a craving for sugary and/or starchy foods.

6. Social functioning - Irritability and desire to avoid social contact

7. Sleep problems - Usually desire to oversleep and difficulty staying awake but, in some cases, disturbed sleep and early morning wakening

8. Lethargy - Feeling of fatigue and inability to carry out normal routine

9. Overeating - Craving for carbohydrates and sweet foods, usually resulting in weight gain

10. Depression - Feelings of misery, guilt and loss of self-esteem, sometimes hopelessness and despair, sometimes apathy and loss of feelings

11. Mood changes - In some sufferers, extremes of mood and short periods of hypomania (overactivity) in spring and autumn.

12. Most sufferers show signs of a weakened immune, system during the Winter, and are more vulnerable to infections and other illnesses.

In sub-syndromal SAD symptoms such as tiredness, lethargy, sleep and eating problems occur, but depression and anxiety are absent or mild.

Symptoms begin in the fall, peak in the winter and usually resolve in the spring. Some individuals experience great bursts of energy and creativity in the spring or early summer. Susceptible individuals who work in buildings without windows may experience SAD-type symptoms at any time of year. Some people with SAD have mild or occasionally severe periods of mania during the spring or summer.

Possible Cause of this Disorder

Melatonin, a sleep-related hormone secreted by the pineal gland in the brain, has been linked to SAD. This hormone, which may cause symptoms of depression, is produced at increased levels in the dark. Therefore, when the days are shorter and darker the production of this hormone increases.

Treatments

Phototherapy or bright light therapy has been shown to suppress the brain's secretion of melatonin. Although, there have been no research findings to definitely link this therapy with an antidepressant effect, many people respond to this treatment. The device most often used today is a bank of white fluorescent lights on a metal reflector and shield with a plastic screen.

For mild symptoms, spending time outdoors during the day or arranging homes and workplaces to receive more sunlight may be helpful. One study found that an hour's walk in winter sunlight was as effective as two and a half hours under bright artificial light. Spending an hour outside each day can often produce beneficial results in some individuals. However, one cannot get early morning outside light in the winter. Not everyone's job will allow for an hour-long outside walk.

Light therapy has been proved effective in up to 85 per cent of diagnosed cases. That is, exposure, for up to four hours per day (average 1-2 hours) to very bright light, at least ten times the intensity of ordinary domestic lighting. Ordinary light bulbs and fittings are not strong enough. Average domestic or office lighting emits an intensity of 200-500 lux but the minimum dose, necessary to treat SAD is 2500 lux, The intensity of a bright summer day can be 100,000 lux!

Light treatment should be used daily in Winter (and dull periods in summer) starting in early Autumn when the first symptoms appear. It consists of sitting two to three feet away from a specially designed light box, usually on a table, allowing the light to shine directly through the eyes. The user can carry out normal activity such as reading, working, eating and knitting while stationary in front of the box. It is not necessary to stare at the light although it has been proved safe. Treatment is usually effective within three or four days and the effect continues provided it is used every day. Tinted lenses, or any device that blocks the light to the retina of the eye, should not be worn. Some light boxes emit higher intensity of light, up to 10,000 lux, which can cut treatment time down to half an hour a day.

How the Light Box is used

 

Before embarking on a course of light treatment, it is best to have a complete psychiatric evaluation. Sometimes a medical illness or another psychiatric condition can masquerade as depression. Discuss various treatment alternatives with your doctor. Light therapy does take time, and regular use. Like exercise, not everyone who would benefit from it will actually do it on a regular basis. The time spent in front of the light is related to the intensity of the light source and the distance one sits from the light.

The light devices cost between $250 to $500 and often are not covered by insurance. Some individuals who use a 10,000-lux box may only need 30 minutes of daily light treatment. However, the amount of light needed varies widely from individual to individual. The light treatment is most often done in the morning, but studies have suggested that either morning or evening light can help SAD.

Some people may get insomnia when they use the light in the evening. Initially, researchers felt that one needed full spectrum light. Now, studies suggest that regular fluorescent lights will work as well. UV (ultraviolet) light can damage eyes and skin, so it must be filtered out. It is best to buy a commercially built light box to be sure of the exact amount of light and to be sure that there are no isolated "hot spots" which could damage eyes.

Many people still prefer full spectrum (minus UV) light because it is closest to natural lighting. The individual measures the distance from her face to the light source. This measurement is important, and should be repeated daily for several days and occasionally after that. The light needs to strike one's eyes, but one does not need to look directly into the light source. It is fine to occasionally glance directly into the light. Many people read a book or eat breakfast while using the lights.

Sitting still for 30 minutes to several hours is not an option for some people. For these people, a "light visor" may be a better option. Others are able to take one of the compact light boxes to work and use it for several hours. It is best to use the light source in an uninterrupted time block, but it can be helpful even with some interruptions.

 

Long term treatment compliance is often more difficult than one might initially anticipate. This is an important reason to have a professional monitoring. Having to account for your regular use (or the lack thereof) is a powerful motivator. It is also helpful to have an outside objective individual to help monitor your response to the treatment.

 

Since one of the symptoms of SAD can be difficulty awakening in the morning, some find it helpful to have the light turn on just before they are supposed to wake up. Some individuals like to use a Dawn Simulator. This is a bright light that is programmed to gradually increase its intensity such that it reaches its full intensity a set period before the individual is scheduled to awaken.

 

Some people like to use full spectrum light bulbs for everyday household use. There is no evidence that these low intensity bulbs affect mood or sleep phase. Your plant light will not cure your SAD. Your 10,000-lux light however, may be nice for some of your plants.

 

Other treatments:

 

Outdoor light, even when the sky is overcast, provides as much or more light than a light box. Outside light is often brighter than the light boxes. However, only highly motivated people will continue their daily walk when it rains or snows.

 

If phototherapy doesn't work, an antidepressant drug may prove effective in reducing or eliminating SAD symptoms, but there may be unwanted side effects to consider. Discuss your symptoms thoroughly with your family doctor and/or mental health professional. Psychotherapy, counselling or any complementary therapy which helps the sufferer to relax, accept their illness and cope with its limitations are extremely useful. Psychotherapy can help the depressed individual look at her depressive assumptions and negative expectations. It can also help one identify relationship difficulties so that interpersonal mistakes might not be repeated. Research has shown that cognitive psychotherapy does help relieve depression faster and more completely than no therapy.

 

Daily exercise has been shown to be helpful, particularly when done outdoors. For those who tend to crave sweets during the winter, eating a balanced diet may help one's mood. Conversely, as the mood improves, craving for sweets may abate.

 

Some people have a certain amount of energy fluctuation with the seasons. If you are aware of your fluctuating moods and energy levels you can plan for them and work the expected fluctuations into your daily routein. You can learn how to manage them and apply that knowledge when you feel your mood shifting.

 

Other Possible Diagnosis

 

Sleep Disorders

 

Humans and animals generally have innate sleep-wake cycles close to but not exactly 24 hours. They depend on the daily light-dark cycle to keep their circadian rhythms to a regular 24 hours. If a human is left in a room with no light-dark cues, he or she will gradually shift into a sleep-wake cycle that is not exactly 24 hours long. Body temperature and the secretion of the hormone melatonin follow the daily cycle.

 

Other factors, such as work schedule can modify the sleep-wake cycle in humans. The autonomous cycle length varies at different periods in the life span. Adolescents often have an innate cycle longer than 24 hours so that they have the desire to stay up late and sleep in when it is time to get up. The innate cycle then shifts closer to 24 hours for adults, but for the elderly, the autonomous sleep-wake cycle may be shorter than 24 hours resulting in evening tiredness, sleep difficulty and waking too early.

 

Individuals who have more severe difficulty with the timing of their sleep-wake cycle may have either Delayed Sleep Phase Disorder (difficulty falling sleep and the urge to sleep late) or Advanced Sleep Phase Disorder (tiring too early and waking too early) Both conditions can be treated with bright light. However, the proper timing of the exposure to light and darkness is more critical than it is for SAD. In these conditions, improperly timed light and dark exposure can make the problem worse, not better.

 

Jet Lag and Shift Work

 

In the cases of jet lag or shift work, the individual does not have a disorder, but is reacting to externally induced changes in the sleep-wake cycle. Traveling west to east over three or more time zones is the most difficult shift. Large forced changes in the timing of sleep periods can lead to irritability and decreased alertness. Many people can deal with this by getting extra rest while traveling or by switching to a job with a more regular schedule.

 

However, for those who must deal with frequent sleep timing changes, one may use a special calculator to help determine the timing for exposure to light and darkness just before and during travel or shift change. If one calculates the timing wrong, one may actually make the time phase shift worse instead of better. A travel kit can consist of a calculator, a light visor and special extra dark glasses. Some use small timed doses of Melatonin to achieve the same purpose.

 

SAD is recognized in the DSM-IV (The American Psychiatric Association's diagnostic manual) as a subtype of major depressive episode. The classic major depression involves decreased appetite, decreased sleep, and often, poor appetite and weight loss. It has long been recognized that some depressed individuals had a "atypical depression" with increased sleep and appetite along with decreased energy. Some, but not all of these atypical individuals also had a seasonal pattern.

 

Some people with winter depression also have mild or occasionally severe manic mood swings in the spring and summer. If these episodes are severe, the individual might be diagnosed with Bipolar Disorder. (formerly called manic depressive illness)

 

Does light therapy cause side effects?

 

1. Photophobia (eye sensitivity to light)

2. Headache " Fatigue " Irritability

3. hypomania (a mental state characterized by excessive excitability, optimism, hyperactivity, talkativeness, heightened sexual interest, quick anger and irritability and a decreased need for sleep)

4. Insomnia (if light therapy is used too late in the day) Possible retinal damage (though this side effect has not been proven)

 

Side Effects Potential side effects of light therapy are rare and most often include jitteriness, a feeling of eyestrain and headache. Light therapy, like antidepressant medications, occasionally will cause someone to switch into a manic state.

 

There has been debate on whether there might be long term retinal effects, but none have been documented when lights with proper screening of UV wavelengths are used. Individuals taking certain medications such as Lithium, tricyclic antidepressants, and neuroleptics and individuals with conditions such as diabetes or retinal degeneration should be monitored by an ophthalmologist. Because this form of treatment is fairly new, many doctors recommend a baseline eye exam and annual monitoring.

 

 

Resources for people with seasonal affective disorder:

 

Light Fixtures Sources Apollo Light Systems 352 West 1060 South Orem, Utah, 84058 1 (800) 545-9667

 

Hughes Lighting Technologies 34 Yacht Club Drive Lake Hopatcong, NJ 07849 (973) 663-1214

 

Northern Light Technologies 8971 Henri Bourassa West Montreal, Canada H45 1P7 1 (800) 263-0066

 

The SunBox Company 19217 Orbit Drive Gaithersburg, MD 20879 1 (800) 548-3968

 

Information Sources National Organization for Seasonal Affective Disorders (NOSAD) P.O. Box 40190 Washington, DC 20016

 

National Depressive and Manic Depressive Association (NDMDA) 730 N. Franklin, Suite 501 Chicago, IL 60610 1 (800) 82-NDMDA (800-826-3632)

 

Society for Light Treatment and Biological Rhythms 10200 W. 44th Ave, #304 Wheat Ridge, CO 80033-2840 (303) 424-3697

 

National Institute of Mental Health (NIMH) 1 (800) 421-4211

 

National Mental Health Association (NMHA) 1021 Prince St. Alexandria, VA 22314-2971 1 (800) 969-6642
National Mental Health Association 2001 N. Beauregard Street, 12th Floor Alexandria, VA 22311 Phone 703/684-7722 Fax 703/684-5968

Mental Health Resource Center 800/969-NMHA TTY Line 800/433-5959

Society for Light Treatment and Biological Rhythm P.O. Box 591687 174 Cook Street San Francisco, CA 94159-1687

 

 

For More Information: Contact your local Mental Health Association, community mental health center

 

References: Rosenthal, NE. Diagnosis and treatment of seasonal affective disorder. JAMA (serial online). 1993; 270(22): 2717-2720. Available at: http//gateway.ovid.com/server3/ovidweb.cgi. Accessed November 6, 1998. Saeed, SA, Bruce, TJ. Seasonal affective disorders. American Family Physician. 1998, 57:1340-1346 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. 1994:327, 390. Agency for Health Care Policy and Research Clinical Practice Guidelines. Depression in primary care. Rockville, MD. 1993 Winter Blues by Norman Rosenthal 1993, Guilford Press Seasonal Affective Disorder and Phototherapy edited by Rosenthal and Blehar 1989 Guilford Press