Seasonal Affective Disorder (SAD)

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Seasonal Affective Disorder (SAD)

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 blues" as fall turns to winter.

However some people experience an exaggerated form of these symptoms. Their depression and lack of energy become debilitating. Work and relationships suffer. This condition, known as Seasonal Affective Disorder (SAD) may affect over 10 million Americans while the milder, "Winter Blues" may affect a larger number of individuals.

Symptoms of Seasonal Affective Disorder

The typical symptoms of SAD include depression, lack of energy, increased need for sleep, a craving for sweets and weight gain. 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. If the symptoms are mild, no treatment may be necessary. If they are problematic, then a mood stabilizer such as Lithium might be considered. There is a smaller group of individuals who suffer from summer depression.

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).

What Seasonal Affective Disorder Is Like

Angela, mother-of-two spent years down in the dumps until her depressive winter illness was diagnosed as Seasonal Affective Disorder (SAD). Backed by the experts, she bought a high powered light producing device and its twice-daily use helped her beat the blues. The 51 year old office worker, who has a young granddaughter, said "The box is my ray of sunshine". I could not live without it. I would probably be suicidal by now".

Angela, who first became ill in 1989 explained "I was so down. I could not understand what was happening to my body and my mind. The tiredness was unexplainable". "I was admitted to the City Hospital in Birmingham, treated for clinical depression and put on anti-depressants. In 1994, my community psychiatric nurse realized I had a pattern of feeling better in the summer and ill in the winter. I went to a psychiatrist who diagnosed SAD".

Angela, who today uses a box which emits a light intensity of 10,000 lux, said "It was the best investment I have ever made. From October to April, I sit in front of it for half an hour every morning and again in the afternoon and take a portable box with me if I am ever away from home. I am a SAD case, but thanks to light therapy and a positive attitude I hold down a job, look after the family and live an active and enjoyable life."

Women Comprise Majority of SAD Sufferers

About 70-80% of those with SAD are women. The most common age of onset is in one's thirties, but cases of childhood SAD have been reported and successfully treated. For every individual with full blown SAD, there are many more with milder "Winter Blues." The incidence of SAD increases with increasing latitude up to a point, but does not continue increasing all the way to the poles. 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 Texas but develop SAD when she moves to Toronto. Another individual may be symptomatic in New York City, 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 the mode by which bright light can lift depression or reset a sleep cycle. One theory is that an area of the brain, near the visual pathway, the suprachiasmatic nucleus, responds to light by sending out a signal to suppress the secretion of a hormone called melatonin. Brain studies suggest that there is impairment of the serotonin function in neurons leading to the suprachiasmatic nucleus.

Initial theories suggested a pathway from the retina to the suprachiasmatic nucleus. However some recent research indicated that bright light applied to the back of an individual's knee could shift human circadian rhythms. (Daily sleep-wake cycle) This suggests that the bloodstream, not just the neurons of the visual pathways, might mediate the biological clock.

How the Light Box is Used

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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. Your doctor will discuss the various types of light boxes or visors available. 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 about $250 to $500 and often are not covered by insurance. (Your doctor may lend out a box for a month so that the individual can see whether it helps before purchasing a box.)

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, the light visor is an 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. Although it is less gentle, some people will put their light box beside their bed and hook it up to a timer set to turn on shortly before awakening.

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 Uses of Bright Light Therapy

There has been research using light therapy for PMS, obesity and non-seasonal depression. The results have not been as striking as the results for SAD. More research needs to be done. However, it may make sense to use light therapy as an augmentation of other depression treatments or in cases in which the individual is unable to use other forms of treatment. The study on obesity was small and needs to be repeated with a larger, more carefully selected group. The obese individuals may have lost weight because their depression was better. Individuals whose PMS was worse in the winter responded better to light therapy than individuals with PMS without a seasonal variation.

Light and Sleep-Wake Cycles

A recent study, published in Science showed that 13,000lux of bright light applied to the back of each subject's knees could shift their sleep-wake cycles. Researchers used a small low-heat light blanket called a BiliBlanket. This blanket is used to administer phototherapy to newborn infants who have a toxic buildup of Bilirubin in the bloodstream. It costs over $2500 even with a physician's discount. If this is possible, then it might theoretically work for SAD. This study needs to be replicated with individuals of different skin types, and it needs to be specifically tested for SAD. If it were effective and if the price came down, one might be able to use a light blanket for a few hours before waking instead of sitting in front of a light box with eyes open.

Side Effects of Light Therapy

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.

References: Winter Blues by Norman Rosenthal 1993, Guilford Press
Seasonal Affective Disorder and Phototherapy edited by Rosenthal and Blehar 1989 Guilford Press

Seasonal Affective Disorder (SAD)

Symptoms of Seasonal Affective Disorder

Women Comprise Majority of SAD Sufferers

Theories About How Light Affects Mood and Sleep

How the Light Box is Used

Other Uses of Bright Light Therapy

Light and Sleep-Wake Cycles

Side Effects of Light Therapy

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