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Seasonal Affective Disorder: The Recurring Winter Blues Storm

W. Scott West, MD

In the United States, 10 to 20 percent of people have a form of the winter blues, and about half a million people suffer from winter Seasonal Affective Disorder or SAD.

Essentially SAD is Major Depressive Disorder with a seasonal pattern. So while this Grinch may more commonly be associated with a visit in the winter, he might also rear his head in the summer, forming a seasonal pattern. Understanding the signs and symptoms of SAD ... or if a broader scope of clinical depression is forming ... is critical to helping patients struggling with depression experience healthier lives.

To be diagnosed with SAD, patients must have depressive episodes during winter or summer months that meet the criteria for Major Depression for at least two years, and seasonal depressions must be more frequent than non-seasonal depressions. Additionally, the "pattern" should not be better explained by seasonally linked psychosocial stressors such as school or seasonal work issues. SAD can also be seen in bipolar disorders, more likely in bipolar II disorder.

Major Depression may include experiencing the following symptoms for two weeks or longer:

  • Feeling depressed nearly every day
  • Low energy
  • Lack of interest
  • Feelings of hopelessness and worthlessness
  • Sleep problems
  • Difficulty concentration
  • Appetite changes
  • Agitation or sluggishness
  • Thoughts of death or suicide

Summer SAD symptoms:

  • Insomnia
  • Anxiety
  • Agitation
  • Restlessness
  • Poor appetite and weight loss

Winter SAD symptoms:

  • Social withdrawal
  • Excessive appetite with weight gain and carbohydrate craving
  • Excessive sleep
  • Lack of energy

Why does SAD occur?

Depression is impacted by multiple factors including the ability of mood-regulating structures in the brain to function, or disruptions in the body's biological clock, which can be caused by reduced sunlight. With less exposure to sunlight, the biological clock shifts, which regulates mood, sleep, and hormones.

Seasonal changes in serotonin may affect mood, as this can result in altered transmission in critical areas of the brain. Melatonin is a chemical known to affect sleep patterns, and it may be that lack of sunlight stimulates the production of melatonin in some individuals, which may be a factor in the symptoms of sluggishness and sleepiness seen in SAD. The physiology may be affected by neurotransmitter malfunction, receptor or brain circuit disruption, as well as environmental contributions within the body and what is going on in someone's life.

Depression is a leading cause of presenteeism in the United States. This also applies with SAD, which can interfere with the ability of people struggling with SAD to optimally function in the work environment but can extend to school activities and relationships. The symptoms are well known to limit people from fully functioning effectively, compounding social or work problems, social withdrawal, substance abuse, and suicidal thoughts.

Depression is normal just as happiness is normal. Having a bad day or even a few depressive days may not be anything to worry about ... but, if mood changes persist for a week or more, it is best to look into whether a more significant problem is taking hold.

Who is at risk for SAD?

  • Patients with a family history of depression are more likely to develop SAD.
  • Patients with depression or bipolar disorder are more prone to have SAD.
  • Women are more likely to have SAD.
  • Prevalence of winter-type seasonal pattern increases with higher latitudes. People who live farther from the equator are more likely to have SAD.

What are the treatment options for SAD?

Since SAD is Major Depressive Disorder, traditional treatments for depression are generally used with a couple of adaptations. The essential foundational components of good health should be pursued such as exercise, proper nutrition, moderation of alcohol, and consistent, quality sleep habits.

In the mental health field, the following treatment options all have been found to be helpful in alleviating depression:

  • Psychotherapy, especially Cognitive Behavioral Therapy (CBT) with Behavioral Activation (BA), can help to replace negative thoughts with positive thoughts and establish a healthy structure. This therapy can be helpful in addressing some of the situational issues in the environment that set the stage for depression. A seasonal example is the expectation many people desire to have that "Norman Rockwell holiday" experience with their family, but that does not happen. The same family dysfunction that existed before happens again, with memories looping and having the same outcomes. Psychotherapy can help reframe expectations and responses when situations are stressful.
  • Antidepressants can help with symptom reduction. It may be that serotonin reuptake inhibitors have a unique role with SAD, although, in many clinical experiences, all categories of antidepressants can be helpful.
  • Transcranial Magnetic Stimulation (TMS) Therapy can help to decrease the seasonal component in patients who have an established depression. Many patients have commented that since they had TMS, they experience less mood decline in the winter.
  • Light Therapy, using specialized lightboxes that filter out harmful ultraviolet rays, allow patients exposure to bright light during darker, low-sunlight seasons. Spending more time outdoors during the day can be helpful but is not always practical. The intensity of emitted light should be 10,000 Lux with the reading or eating in front of the light at a distance of two to three feet for 15-30 minutes every morning. Improvement is often seen within two to four days and full benefits reached within two weeks. Symptoms can return if light therapy is stopped so it should be continued throughout the season. Light therapy is generally safe but should not be used with retinopathies, and it can cause mania in some individuals. Side effects of light therapy include insomnia, headache, eye strain, fatigue, and irritability.

When someone is diagnosed with SAD, the above treatment efforts are worth considering as well as the foundational efforts of exercise, nutrition, and maintaining positive social activity. If a patient has responded to light therapy in a previous season, it should be encouraged to initiate light therapy at the beginning of the fall season before symptoms are evident and in some instances increasing psychotherapy or adjusting medications doses can be helpful.

So while the Grinch may visit here and there this winter, it is best to understand whether a patient is experiencing SAD or a more severe form of depression. Depression is a complex and serious disease, so being proactive and paying attention to what is going on with one's emotions, and identifying proper support and treatment are essential practices to helping patients achieve and sustain a more productive, healthier life throughout the year, regardless of the season.


Dr. West


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Antidepressants, Light Therapy, Major Depressive Disorder, Psychotherapy, SAD, Seasonal Affective Disorder, Seasonal Depression, ThriveLogic TMS, Transcranial Magnetic Stimulation Therapy, W. Scott West, Winter Blues
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