Unless you're an avid skier or snowboarder, you probably don't relish the onset of a long winter. For certain people who live in northern climates, the cold, dark days of winter make them feel so sluggish and withdrawn it's hard to get out of bed.
People who start feeling depressed in the fall or winter, but experience relief from their symptoms with the buds of spring, may have seasonal affective disorder or SAD. For those who are diagnosed with this condition, light therapy, or other treatments, can restore their energy and alleviate their depression. Below, Dr. Michael Terman, a professor of clinical psychology at the Columbia University College of Physicians and Surgeons in New York, discusses how to identify and cope with seasonal depression.
What is seasonal affective disorder?
Seasonal affective disorder is characterized by symptoms that start in the fall and snowball in the winter months, and then spontaneously disappear come springtime. It usually starts off with feelings of fatigue, difficulty getting up in the morning, a big afternoon slump and cravings for carbohydrate-rich foods. Coupled with that fatigue, and you have a formula for significant weight gain.
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As the symptoms increase, you begin to see depression and a lack of interest in activities. It's difficult to concentrate and get through the day. There's a withdrawal from social contact, including a depressed sex drive, which would be normal during the spring or summer.
One of the classic symptoms is what experts call hypersomnia, where you sleep significantly longer than you sleep in the summer. Hypersomnia is different from person to person, for example if you're a 6-hour sleeper in the summer, you might start sleeping 8 to 9 hours in the winter, and become relatively hypersomnic. But some people will start to sleep 12 or 14 hours a day.
Are there different degrees of SAD?
SAD exists in degrees of severity. Full-blown SAD means literally that you have a clinically severe major depressive episode during the winter. "But many people show the same cluster of physical symptoms and feel only mildly depressed during the winter," says Terman, "and experts call that sub-SAD."
Who is at increased risk for SAD?
SAD is widely prevalent throughout the population, and it is worse the farther north you go. In the middle tier of the United States, up to Southern Canada, it's far more prevalent than in the southern states. And most of the people who have SAD have depression in their family.
Are women at higher risk than men?
There is no question that more women than men have reported symptoms and sought counseling and/or treatment. And more women than men have participated in research studies. "I think it's somewhat more likely that a woman will suffer from SAD," says Terman, "but that's not to minimize the impact on men. It's terribly important to teach men that this can hit them just as severely and not to brush it away."
What causes SAD?
The nervous system relies on a daily exposure to early morning light for the internal biological clock to stay synchronized with the external world. In the fall, the sun is rising later and later in the morning. "So when we allow our internal clock to drift later as sunrise drifts later and the days grow shorter," Terman says, "that's when we see the onset of both the physical and the emotional symptoms."
How do you differentiate between SAD and normal depression?
One mistake that doctors often make when a patient comes in with a depression is that they fail to note the time of year, and fail to ask what the patient's mood was like at the opposite time of year. So a person comes in November and is feeling lousy. The first question to ask is: "How were you feeling in June and July?" Next question to ask is: "How were you feeling at this time last year and the year before?"
Is diagnosis often delayed?
The fortunate aspect of SAD is that you know it's going to pass, whereas in other depressions you can't be sure. There are even depressions that last for years. So the SAD sufferer has that firm knowledge that, "Come the second week of May, I'm going to be back to myself."
For that reason, many patients with SAD have resisted coming in for clinical care, because they say, "I'll bear it out, and I know I'll be better." And it's a mistake, because their lives can be severely compromised for five to six months of the year unnecessarily.
How are the holiday blues tied to SAD?
It's not difficult to confuse holiday depression with SAD because of the timing. While some people with SAD begin to feel the effects as early as September and October, a large number really don't feel the major slump until after Thanksgiving and towards Christmastime. You'll know, however, that the holidays aren't the trigger for your depression when your symptoms don't pass until April or May. Usually a holiday depression will pass shortly after New Year's while January and February are the worst months of the year for SAD suffers.
How is SAD treated?
Winter depression will respond well to a number of different interventions. The primary therapy is bright light therapy in the morning after you wake up. Another light therapy option includes dawn simulation therapy, in which you force an artificial sunrise in your bedroom while it's still dark outside. Another option is negative air ionization therapy, where you create summer-like conditions in the circulating air environment, either while you sleep or during the day. Negative air ions are very high in the environment, but indoors, especially in the winter with the heater on, there's a scarcity, and that acts badly on mood.
Another option is standard antidepressant medication, which you really need to use only during the difficult months of the year. "What we realize now is that the whole gamut of depression, whether seasonal or not, is modulated by the level of serotonin, a neurotransmitter in the brain, that is responsible for mood," says Terman. That's why the selective serotonin reuptake inhibiting (SSRI) drugs, such as Prozac, Zoloft or Celexa, are useful for depression. They activate the serotonin system, and mood lifts. The studies that have been completed so far on SSRI drugs for SAD do show some improvement, but with not the extreme and rapid alleviation of symptoms that is seen with light therapy. And finally, there are indications that cognitive behavioral therapy can be effective in helping people deal with the challenges of winter and lifting their mood and improving their function.
How does bright light therapy work?
"When we use bright light therapy, we're introducing a level of light indoors that does not come from any normal home lighting appliance," says Terman. It's a level equal to outdoor light about 40 minutes after the sun rises.
The light box is set up on a desk or kitchen table such that the angle of light exposure comes down at your eyes. Its action is on the eyes, not the skin. There are light receptors in the eyes that are specialized for sending signals to the biological clock. "When we stimulate those receptors with light at the appropriate time of day for the individual, it resets the clock to its springtime mode," Terman says, "and that's when we begin to see the alleviation of symptoms." The average treatment duration is 30 minutes a day.
Are there side effects of light therapy?
It's critical when you use light therapy to use well-designed apparatus that completely screens out ultraviolet (UV) rays. The long-term cumulative exposure to UV rays is bad for the skin, and for the cornea and lens of the eyes. Unfortunately, there is a wide array of devices available for sale on the market, which has never been medically evaluated, and the Food and Drug Administration has no regulatory policy for this technology. But there are reliable products out there. It is always best to consult your doctor before purchasing any light therapy devices, especially if you have any questions.
Should people with symptoms that are not alleviated by therapy move?
"Many people who have suffered this terribly at Northern locations, like New England or Minnesota, will ask me, ‘Should I make a major life change and move down to Atlanta or Miami or Dallas?'" And the answer is, it's worth a try, but don't make the commitment to move until you have taken an extended vacation at that location in winter. A change in location does not always guarantee a cure to your seasonal depression.