Seasonal Affective Disorder

By Fauzia Saeed, Psychologist, PRCS Punjab Branch, Lahore

Some people suffer from symptoms of depression during the winter months, with symptoms subsiding during the spring and summer months.  These symptoms may be a sign of seasonal affective disorder (SAD).  SAD is a mood disorder associated with depression and related to seasonal variations of light.  SAD affects half a million people every winter between September and April, peaking in December, January, and February.  The “Winter Blues,” a milder form of SAD, may affect even more people.

What is seasonal affective disorder?

Seasonal affective disorder is a type of depression that tends to occur (and recur) as the days grow shorter in the fall and winter. It is believed that affected persons react adversely to the decreasing amounts of light and the colder temperatures as the fall and winter progress. It is important to note that although seasonal affective disorder usually presents in the fall and winter, there are those who suffer from this condition during the summer instead of, or in addition to, during the fall or winter.

Seasonal affective disorder has not been long recognized as a medical condition. The term first appeared in print in 1985. Seasonal affective disorder is also sometimes called winter depression, winter blues, or the hibernation reaction.

The incidence of seasonal affective disorder increases in people who are living farther away from the equator. Seasonal affective disorder is less common where there is snow on the ground. Seasonal affective disorder is more common in women than men. People of all ages can develop seasonal affective disorder.

What are the symptoms of seasonal affective disorder?

Symptoms of seasonal affective disorder include tiredness, fatigue, depression, crying spells, irritability, trouble concentrating, body aches, loss of sex drive, poor sleep, decreased activity level, and overeating, especially of carbohydrates, with associated weight gain. When the condition presents in the summer, the symptoms are more commonly insomnia, poor appetite and weight loss, in addition to irritability, difficulty concentrating, and crying spells. In severe instances, seasonal affective disorder can be associated with thoughts of suicide.

The symptoms of seasonal affective disorder typically tend to begin in the fall each year, lasting until spring. The symptoms are more intense during the darkest months. Therefore, the more common months of symptoms will vary depending on how far away from the equator one lives.

What are the symptoms of SAD?

Although your symptoms are clues to the diagnosis, not everyone who has SAD experiences the same symptoms. Common symptoms of winter-onset SAD include the following:

• A change in appetite, especially a craving for sweet or starchy foods
• Weight gain
• A drop in energy level
• Fatigue
• A tendency to oversleep
• Difficulty concentrating
• Irritability and anxiety
• Increased sensitivity to social rejection
• Avoidance of social situations and a loss of interest in the activities you used to enjoy

Symptoms of summer-onset SAD include:

• A loss of appetite
• Weight loss
• Insomnia
• Irritability and anxiety
• Agitation
• Increased sex drive

Either type of SAD may also include some of the symptoms that are present in other forms of depression. These symptoms include feelings of guilt, ongoing feelings of hopelessness and physical problems (such as headaches).

Symptoms of SAD keep coming back year after year. They also tend to come and go at about the same time every year. The changes in mood are not necessarily related to obvious things that would make a certain season stressful (like regularly being unemployed during the winter).

Symptoms

A diagnosis of SAD can be made after three consecutive winters of the following symptoms if they are also followed by complete remission of symptoms in the spring and summer months:

• Depression: misery, guilt, loss of self-esteem, hopelessness, despair, and apathy
• Anxiety: tension and inability to tolerate stress
• Mood changes: extremes of mood and, in some, periods of mania in spring and summer
• Sleep problems: desire to oversleep and difficulty staying awake or, sometimes, disturbed sleep and early morning waking
• Lethargy: feeling of fatigue and inability to carry out normal routine
• Overeating: craving for starchy and sweet foods resulting in weight gain
• Social problems: irritability and desire to avoid social contact
• Sexual problems: loss of libido and decreased interest in physical contact

Diagnostic criteria

According to the American Psychiatric Association DSM-IV,criteria, Seasonal Affective disorder is not regarded as a separate disorder, rather it is termed a ‘specifier’ and may be applied as an added description to a Major Depressive Episode in patients with Major Depressive Disorder or patients with Bipolar Disorder. The Seasonal Pattern Specifier must meet four criteria: depressive episodes at a particular time of the year; remissions or mania/hypomania also at a characteristic time of year; these patterns must have lasted two years with no nonseasonal major depressive episodes during that same period; and these seasonal depressive episodes outnumber other depressive episodes throughout the patient’s lifetime. The Mayo Clinic describes three types of Seasonal Affective Disorder, each with its own set of symptoms.

What causes seasonal affective disorder?

Seasonal affective disorder seems to develop from inadequate bright light during the winter months. Researchers have found that bright light changes the chemicals in the brain. Exactly how this occurs and the details of its effects are being studied.

For Example

1. As sunlight has affected the seasonal activities of animals (i.e., reproductive cycles and hibernation), 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.
2. 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.

Prevalence

1. Three out of four SAD sufferers are women. 
2. The main age of onset of SAD is between 18 and 30 years of age. 
3. SAD occurs in both the northern and southern hemispheres, but is extremely rare in those living within 30 degrees latitude of the equator. 
4. The severity of SAD depends both on a person’s vulnerability to the disorder and his or her geographical location.

What is the treatment for seasonal affective disorder?

Regular exposure to light that is bright, particularly fluorescent light, significantly improves depression in people with seasonal affective disorder that presents during the fall and winter. The light treatment is used daily in the morning and evening for best results. Temporarily changing locations to a climate that is characterized by bright light (such as the Caribbean) can achieve similar results. Light treatment has also been called phototherapy.

Phototherapy is commercially available in the form of light boxes, which are used for approximately 30 minutes daily. The light required must be of sufficient brightness, approximately 25 times as bright as a normal living room light. Contrary to prior theories, the light does not need to be actual daylight from the sun. It seems that it is quantity, not necessarily quality of light, that matters in the light treatment of seasonal affective disorder. The most common possible side effects associated with phototherapy include irritability, insomnia, headaches, and eyestrain.

Antidepressant medications, particularly those from the serotonin selective reuptake inhibitor family (SSRI) family, have been found effective treatment for seasonal affective disorder that presents during summer as well as that which tends to occur during the fall or winter. Examples of SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa). Common side effects for this class of medications include insomnia, nausea, diarrhea, and decreased sex drive or performance. As with any other mood disorder, psychotherapy tends to accentuate the effectiveness of medical treatment and therefore should be included in the approach to addressing this disorder.

• 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.
• If phototherapy does not 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.

What causes seasonal affective disorder?

Seasonal affective disorder seems to develop from inadequate bright light during the winter months. Researchers have found that bright light changes the chemicals in the brain. Exactly how this occurs and the details of its effects are being studied.

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How common is SAD?

As many as half a million people in the United States may have winter-onset depression. Another 10% to 20% may experience mild SAD. SAD is more common in women than in men. Although some children and teenagers get SAD, it usually doesn’t start in people younger than 20 years of age. For adults, the risk of SAD decreases as they get older. Winter-onset SAD is more common in northern regions, where the winter season is typically longer and more harsh.

Is there a treatment for SAD?

Yes, treatment is available for SAD. Winter-onset SAD is most likely caused by your body’s reaction to the lack of sunlight. Light therapy is one option for treating this type of SAD because increased sunlight can improve symptoms.

If your doctor suggests you try light therapy, you may use a specially made light box, or a light visor that you wear on your head like a cap. You will sit in front of the light box or wear the light visor for a certain length of time each day. Generally, light therapy takes about 30 minutes each day throughout the fall and winter, when you’re most likely to be depressed. If light therapy helps, you’ll continue it until enough sunlight is available, typically in the springtime. Stopping light therapy too soon can allow the symptoms to come back.

When used properly, light therapy seems to have very few side effects. However, some side effects may include eyestrain, headache, fatigue, irritability and inability to sleep (if light therapy is used too late in the day). Light therapy should be used carefully in people who have manic depressive disorders, skin that is sensitive to sunlight and/or medical conditions that make their eyes vulnerable to sunlight damage.

Tanning beds should not be used to treat SAD. The light sources in tanning beds are high in ultraviolet (UV) rays, which harm both your eyes and your skin.

Your doctor may also want you to try medicine or behavior therapy to treat your SAD. If light therapy or medicine alone doesn’t work, your doctor may want you to use them together.

Seasonal Affective Disorder

Also called: SAD, Seasonal depression, Seasonal mood disorder

Some people experience a serious mood change when the seasons change. They may sleep too much, have little energy, and crave sweets and starchy foods. They may also feel depressed. Though symptoms can be severe, they usually clear up. This condition is seasonal affective disorder (SAD). It usually happens during the winter. A less common type of SAD happens in the summer.

What causes SAD? Some experts think it’s a lack of sunlight during winter, when the days are shorter. In the United States, it is much more common in northern states. Light therapy, in which patients expose themselves to a special type of light for 30 minutes every day often helps. Other treatments include

• Medicines
• Changes in diet
• Learning to manage stress
• Going to a sunny climate during the cold months

Pathophysiology

Seasonal mood variations are believed to be related to light. An argument for this view is the effectiveness of bright-light therapy. SAD is measurably present at latitudes in the Arctic region, such as Finland (64º 00´N) where the rate of SAD is 9.5% Cloud cover may contribute to the negative effects of SAD.

SAD can be a serious disorder and may require hospitalization. There is also potential risk of suicide in some patients experiencing SAD. One study reports 6-35% of sufferers required hospitalization during one period of illness. The symptoms of SAD mimic those of dysthymia or clinical depression. At times, patients may not feel depressed, but rather lack energy to perform everyday activities. Norman Rosenthal, a pioneer in SAD research, has estimated that the prevalence of SAD in the adult United States population is between about 1.5 percent in Florida and about 9 percent in the northern US.

Various etiologies have been performed. One possibility is that SAD is related to a lack of serotonin, and serotonin polymorphisms could play a role in SAD, although this has been disputed. Mice incapable of turning serotonin into N-acetylserotonin (by Serotonin N-acetyltransferase) appear to express “depression-like” behavior, and antidepressants such as fluoxetine increase the amount of the enzyme Serotonin N-acetyltransferase, resulting in an antidepressant-like effect. Another theory is that the cause may be related to melatonin which is produced in dim light and darkness by the pineal gland, since there are direct connections, via the retinohypothalamic tract and the suprachiasmatic nucleus, between the retina and the pineal gland.

Subsyndromal Seasonal Affective Disorder is a milder form of SAD experienced by an estimated 14.3% vs. 6.1% of the U.S. population. The blue feeling experienced by both SAD and SSAD sufferers can usually be dampened or extinguished by exercise and increased outdoor activity, particularly on sunny days, resulting in increased solar exposure. Connections between human mood, as well as energy levels, and the seasons are well documented, even in healthy individuals.

Mutation of a gene expressing melanopsin has been implicated in the risk of having Seasonal Affective Disorder.

TREATMENT

Another type of light therapy lamp

There are many different treatments for classic (winter-based) seasonal affective disorder, including light therapies, medication, ionized-air administration, cognitive-behavioral therapy and carefully timed supplementation of the hormone melatonin.

Bright light treatment using a specially designed lamp, or light box, provides a much more intense illumination than traditional incandescent bulbs are capable of. The light is usually white “full spectrum”, although blue light is also used. The light box has proven to be effective at doses of 2500 – 10,000 lux, the sufferer sitting a prescribed distance, commonly 30-60 cm, in front of the box with her/his eyes open but not staring at the light source. Most treatments use 30-60 minute treatments, however this may vary depending on the situation. Many patients use the light box in the morning, and there is evidence that morning light is superior to evening light, although people can respond to evening light as well. Discovering the best schedule is essential. One study has shown that up to 69% of patients find the treatment inconvenient and as many as 19% stop use because of this.

Dawn simulation has also proven to be effective; in some studies, there is an 83% better response when compared to other bright light therapy. When compared in a study to negative air ionization, bright light was proven to be 57.1% effective vs. dawn simulation, 49.5%. Patients using light therapy can experience improvement during the first week, but increased results are evident when continued throughout several weeks. Most studies have found it effective without use year round, but rather as a seasonal treatment lasting for several weeks until frequent light exposure is naturally obtained.

SSRI (selective serotonin reuptake inhibitor) antidepressants have proven effective in treating SAD. Bupropion is also effective as a prophylactic. Effective antidepressants are fluoxetine, sertraline, or paroxetine. Both fluoxetine and light therapy are 67% effective in treating SAD according to direct head-to-head trials conducted during the 2006 CAN-SAD study. Subjects using the light therapy protocol showed earlier clinical improvement, generally within one week of beginning the clinical treatment.

Negative air ionization, involving the release of charged particles into the sleep environment, has also been found effective with a 47.9% improvement. Depending upon the patient, one treatment (ie. lightbox) may be used in conjunction with another therapy (ie. medication). Modafinil may be also an effective and well-tolerated treatment in patients with seasonal affective disorder/winter depression.

Alfred J. Lewy of Oregon Health and Science University in Portland, OHSU, and others see the cause of SAD as a misalignment of the sleep-wake phase contra the period of the body clock, circadian rhythms out of synch, and treat it with melatonin in the afternoon. Correctly timed melatonin administration shifts the rhythms of several hormones en bloc.

Another explanation is that vitamin D levels are too low when people do not get enough Ultraviolet-B on their skin. An alternative to using bright lights is to take vitamin D supplements. However, at least one study did not show a link between SAD and vitamin D levels.

INCIDENCE

Nordic countries

Winter depression is a common slump in the mood of some inhabitants of most of the Nordic countries. It was first described by the 6th century Goth scholar Jordanes in his Getica wherein he described the inhabitants of Scandza (Scandinavia). Iceland, however, seems to be an exception. A study of more than 2000 people there found the prevalence of seasonal affective disorder and seasonal changes in anxiety and depression to be unexpectedly low in both sexes. The study’s authors suggested that propensity for SAD may differ due to some genetic factor within the Icelandic population. A study of Canadians of wholly Icelandic descent also showed low levels of SAD. It has more recently been suggested that this may be attributed to the large amount of fish traditionally eaten by Icelandic people, 225 lb per person per year as opposed to about 50 lb in the US and Canada, rather than to genetics. Fish is high in vitamin D.

Other countries

In the United States, a diagnosis of seasonal affective disorder was first proposed by Norman E. Rosenthal, MD in 1984. Rosenthal wondered why he became sluggish during the winter after moving from sunny South Africa to New York. He started experimenting increasing exposure to artificial light, and found this made a difference. In Alaska it has been established that there is a SAD rate of 8.9%, and an even greater rate of 24.9% for subsyndromal SAD. American science fiction-fantasy author Barbara Hambly had undiagnosed SAD for many years and speaks freely about her condition. Around 20% of Irish people are affected by SAD, according to a survey conducted in 2007. The survey also shows women are more likely to be affected by SAD than men. An estimated 10% of the population in the Netherlands suffers from SAD.

SAD and bipolar

Most people with SAD experience major depressive disorder, but as many as 20% may have or may go on to develop a bipolar or manic-depressive disorder. It is important to discriminate the improved mood associated with recovery from the winter depression and a manic episode because there are important treatment differences. In these cases, persons with SAD may experience depression during the winter and hypomania in the summer.

• Circadian rhythm sleep disorder
• Depression (mood)
• Social anxiety disorder
• Vitamin D

Like many people, you may develop cabin fever during the winter months. Or you may find yourself eating more or sleeping more when the temperature drops and darkness falls earlier. While those are common and normal reactions to the changing seasons, people with seasonal affective disorder (SAD) experience a much more serious reaction when summer shifts to fall and on to winter.

With seasonal affective disorder, fall’s short days and long nights may trigger feelings of depression, lethargy, fatigue and other problems. Don’t brush this off as simply a case of the “winter blues” that you have to tough out on your own.

Seasonal affective disorder is a type of depression, and it can severely impair your daily life. That said, treatment — which may include light box therapy — can help you successfully manage seasonal affective disorder. You don’t have to dread the dawning of each fall or winter.