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Seasonal Affective Disorder (SAD)




Excerpted from
Healing Anxiety And Depression
By Daniel G. Amen, M.D., Lisa C. Routh, M.D.

The turkey is roasting in the oven, the fall days have grown crisp with the first hint of winter, and everyone is excitedly waiting for Thanksgiving guests to arrive for dinner-everyone except those suffering from Seasonal Affective Disorder (SAD). People with SAD are not energized by the Indian summer days of fall and do not look forward to the holiday season with joyful anticipation. Instead, they begin to experience the annual onset of the symptoms of this variant of cyclic depression.

SAD is similar in many ways to recurrent Major Depressive Disorder; however it may have more atypical features. Atypical features are oversleeping as opposed to insomnia, weight gain and increased appetite rather than weight loss and loss of appetite, and agitation instead of feeling slowed down. People with SAD feel run-down, irritable, and depressed. They have increased appetite, especially for carbohydrates, and usually gain weight. They also feel like they never get enough rest even though they are sleeping more than usual. Some describe themselves as feeling like a grouchy bear that needs to hibernate during the winter.

The holiday season is difficult for many people. Financial pressures and the expectations of family members are great. For those of us who have lost a loved one or are alone, grief reactions can be intense during the holidays. Typically, the "holiday blues" resolve rapidly with social support or without intervention after the first of the year. SAD, on the other hand, continues to intensify during the holiday season, the winter months, and into early spring. Without intervention, the symptoms do not begin to abate until early to mid-spring, or until summertime for some patients, when the days are longer.

The most likely explanation for the cause of SAD is light deprivation. Sunlight detected by the retina of the eye sends signals to the more primitive parts of the brain, one of which is the pineal gland. The pineal gland plays a vital role in hormone regulation, and one of the hormones it controls is melatonin. Melatonin, in turn, helps set the body's biorhythms. Disruption of the pineal gland hormonal axis is thought to be a primary cause of SAD. Support for this line of thought comes from several observations. First, SAD is decidedly more common in parts of the world that are more deprived of sunlight. In the United States, the rate of SAD is much higher in the Pacific Northwest and in Maine than in Ohio, and the rate is highest in Alaska. The rate of SAD is higher in Scandinavian countries than in southern European countries. Second, people with SAD who travel to a more southern location experience improvement in their symptoms. Third, the development of bright light therapy, discussed below, has proved beneficial for SAD patients who are not fully responsive to other forms of treatment.

Children are not immune to SAD. In fact some of us who have a great deal of experience with SAD (Dr. Routh practiced in Alaska for several years and continues to consult there) believe children may be more vulnerable to the disorder. Native Alaskans have a high rate of SAD, which may come as a surprise to many people who may assume that Native Alaskans should be used to light deprivation since they have lived for generations in such an environment. Once again, those of us who have lived with and worked with this population have observed that these populations have undergone tremendous changes in their social structures in the past two generations, and consequently protective mechanisms against mental illnesses including SAD have broken down.

We have written about the many variations of depression and anxiety disorders and there are variant forms of SAD as well. Some individuals living in the very hot regions of the United States experience the onset of depressive symptoms in the summertime and feel better in the winter. For these people, the trigger is not light deprivation but too much heat or possibly light.

Many people with SAD respond to antidepressants. Because they tend to have atypical symptoms of overeating and weight gain, fatigue, feeling run-down. and an increased need for sleep, they usually respond best to an antidepressant that either helps with appetite control or at least doesn't increase their appetite. Therefore, those of us who treat SAD patients prescribe Wellbutrin or an SSRI like Prozac. These two antidepressants can be used alone or in combination and combined with medications for the treatment of anxiety disorders or with anticonvulsants/mood stabilizers. There are some patients with SAD who don't fully respond to treatment regardless of which antidepressant is used. They get better, but they don't get well. These patients are the ones who typically need sunlight. Unfortunately, most insurance companies won't pay for therapeutic trips to Hawaii even though in many cases a trip would cost less than ongoing treatment. Most people are not in a position to move to the Southwest or Texas or Florida on "doctor's orders," either, so we prescribe bright light therapy.

Tanning beds do not provide bright light therapy. It you try to treat your SAD by going for tanning booth sessions, it won't work. You'll ruin your skin, get wrinkles earlier, and only give yourself more reasons to be depressed. Bright light therapy is full-spectrum light and it has to be at least 10,000 lux or higher to be effective. "Full spectrum" is important terminology; it means that the light is the same color spectrum as sunlight. Other types of light won't do for the treatment of SAD. How the light is used is also extremely important. Overhead lights won't work nor will any of those gimmicks you see in magazines like lights in visors or hats. Full-spectrum light panel boxes (10,000 lux or higher) need to be placed close enough for you to get intense exposure, and this means two to four feet from your eyes and at eye level. You need to be in the presence of the light for an hour every morning, and you may need another hour in the afternoon as well. Periodically during the hour that you sit with the light, you need to glance at it for a few seconds so that it stimulates the retina and sends signals to your brain. You can read, cook, or watch TV as long as you remember to look at the light.

Many people have a dramatic response to bright light therapy. Light therapy can be used alone or in combination with medication to boost its effectiveness.



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