Psychotherapist, Stelios Kiosses explores how natural light, and the lack of it in the winter, can affect our psychological health
Do you feel slowed down and have difficulty waking up in the morning?
Do you feel you want to eat more through the dark days of winter, and do you find it hard to focus at work and socialise while at the same time feeling depressed?
If you answered yes to one or more of these questions you may be one of the millions of people around the world who have problems with the changing seasons and you may suffer from a condition now widely accepted by the medical community and the public at large as Seasonal Affective Disorder or SAD.
Seasonal Affective Disorder is a depression brought on by a lack or deficit of natural light (i.e. sunlight). According to the Diagnostic and Statistical Manual of Mental Disorders DSM-5, criteria for depression with a seasonal pattern include having depression that begins and ends during a specific season every year (with full remittance during other seasons) for at least two years and having more seasons of depression than seasons without depression over a lifetime.
The term ‘Seasonal Affective Disorder’ was coined in the 1980s by Norman Rosenthal, MD, a psychiatrist and research scientist who studied mood and biological rhythm disorders at the National Institutes of Mental Health. In his best-selling book Winter Blues, he revealed his struggle with SAD.
Many of us now recognise that our moods change with the revolving years and seasons. However, the effect of the seasons on our moods has long been a subject of discussion through the centuries with artists, poets, and philosophers. As in the classic Shakespearean writing remark “a sad tale is best for winter”.
My favourite myth is how the Greek Gods suffered during the winter months: Persephone was banished to the underworld every winter, while Boreas ushered in the cool winter winds and his nasty temper.
The human body responds to daylight: we rise when the sun comes up and we go to bed once it’s gone down. And this is not just in our modern times. As humans, we are attuned to the patterns of light and dark to maintain our circadian rhythms. (Circadian rhythms regulate many of our body’s functions, including our appetites and our moods).
It is thought that insufficient sunlight has a direct effect upon the part of the brain that contains the hypothalamus. The hypothalamus is a region of the forebrain that controls the body’s autonomic nervous system and the pituitary gland. This, in turn, may affect the production of the hormone melatonin in the body.When working normally, this hormone makes us feel tired, but when it is sunlight-deprived, more melatonin than usual may be produced, making us feel more tired, more often. The production of serotonin may also be affected by insufficient sunlight. This hormone affects mood, sleep patterns and appetite and if our bodies do not produce enough serotonin, we often begin to feel depressed. Lower levels of sunlight exposure affects the natural rhythm of our bodies and any disruption to your body’s clock can result in suffering some symptoms of SAD.
Further, with less outdoor exposure to sunlight on the skin in winter, people with SAD may produce less Vitamin D. As Vitamin D is believed to play a role in serotonin activity, Vitamin D deficiency and insufficiency have been associated with clinically significant depressive symptoms. Causal links between serotonin, melatonin, circadian rhythms, Vitamin D, and SAD have not yet been confirmed. However, associations among these key factors are present and are continuing to be researched.
Who is affected by SAD?
Depression can strike anyone at any time, but some groups are more susceptible to developing SAD than others. These groups can be categorised as follows:
1. 20-40 year old age group;
2. women in their 20s and 30s;
3. and women rather than men.
Some individuals may experience a milder form of SAD known as subsyndromal or S-SAD, or most commonly known as ‘winter blues’.
Those living farthest from the equator in Northern latitudes are most susceptible. For example, in the United States, 1% of those who live in Florida and 9% who live in Alaska experience SAD. In Canada, 15% of the population experience winter blues and 2 to 6% experience SAD. In the United Kingdom, 20% experience winter blues and 2% experience SAD.
However, pinpointing prevalence is difficult as the disorder may go unreported and consequently under- diagnosed. Furthermore, SAD can cooccur with other depressive issues like bipolar, attention deficit, alcoholism, and eating disorders, making it difficult to diagnose. The symptoms of SAD tend to be the typical symptoms of depression, including:
• increased sleep,
• increased appetite and carbohydrate cravings,
• weight gain,
• irritability,
• interpersonal difficulties (especially rejection sensitivity),
• a heavy, leaden feeling in the arms or legs,
• feelings of despondency and hopelessness characteristic of depression,
• lack of energy, and difficulty carrying out a normal routine; inactivity,
• increased appetite and a tendency to overeat, leading to weight gain,
• withdrawal from friends, family and social activities,
• feelings of anxiety and an inability to cope,
• difficulties in concentration; frustration and irritability,
• and feelings of worthlessness and guilt.
It is important for the health and aesthetic practitioner, if they suspect that a patient may suffer from SAD, that they do an initial screen of the patient using the Seasonal Pattern Assessment Questionnaire (SPAQ). The SPAQ is a retrospective, self- administered tool that screens for the existence of SAD and S-SAD.
It is freely available in the public domain and can be downloaded from http://www.guilford.com/add/forms/ rosenthal2.pdf. No training is required to use the tool.
How to Avoid Winter Depression – Light therapy
Treatment approaches typically include combinations of antidepressant medication, light therapy, Vitamin D, and counselling.
There are some self-care steps you can take all year long that may help reduce your risk of SAD, too. They include exercising regularly, maintaining healthy sleep habits and a predictable sleep/wake cycle, eating a healthy diet and limiting the amount of sugary foods you eat.
Also, going outside on sunny days can make a difference. Exposure to natural sunlight can help ease SAD. Light box therapy is also particularly useful. Light boxes mimic outdoor light by emitting a broad-spectrum ultraviolet light. The most common prescription is 30 minutes of light box use at the beginning of every morning, with the box 12 to 24 inches away.
The intensity of the light box is recorded in lux, which is a measure of the amount of light you receive at a specific distance from a light source. The recommended intensity of the light typically is 10,000 lux.
For light therapy to work, the light must enter a patient’s eyes indirectly – this does not mean staring directly into a light box, rather the box must be facing the person while they work, read, or relax.
Sunrise alarm clocks have become increasingly popular in recent months, especially among people who experience SAD. The clocks come with gentle sunrise and sunset features, allowing users to wake up and go to sleep in a setting that mimics natural light.
How to Avoid Winter Depression – Psychotherapy
A combination of lig and CBT has been shown to significantly reduce symptoms in sufferers, both in the short and long-term. Cognitive Behavioural Therapy (CBT) is a psychological treatment which helps to change the way you think, feel and behave.
Although SAD has been shown to have a biological basis, it is often accompanied by negative automatic thoughts, pessimistic attitudes, withdrawal from social activities, and rumination; thus, CBT can be particularly helpful in targeting these negative thoughts and behaviours.
Finally. there are some simple steps anyone can try that may help improve symptoms:
• Get as much natural sunlight as possible.
• Make your work and home environments as light and airy as possible.
• Sit near the windows when you’re indoors.
• Take plenty of regular exercise, particularly outdoors and in daylight.
• Eat a healthy, balanced diet.
• Manage your stress levels.
• A winter holiday to a sunny location can also do wonders for your state of mind, and some people suffering from SAD truly consider it a health requirement.
• Some SAD sufferers manage their symptoms with vitamin D supplements in the autumn and winter months.
• Snacking on the right kinds of carbohydrates can relieve some of the symptoms of SAD such as popcorn, shredded wheat squares or low-fat biscuits.
• Research has suggested that SAD is less common in those
who consume more omega-3 fatty acids. Take a supplement with a high concentration of fish oil.
The good thing is that winter isn’t forever and, the moment spring returns, the symptoms of SAD fade away.
Furthermore, there is no need to suffer in silence. If SAD is impacting the quality of your life, make lifestyle changes to ease symptoms and consider seeking out a treatment that helps you manage your symptoms and continue living your life. Managing Seasonal Affective Disorder is possible.
References
• R. Anglin, Z. Samaan, S. Walter, and S. McDonald, “Vitamin D deficiency and depression in adults: systematic review and meta-analysis,” British Journal of Psychiatry, vol. 202, no. 2, pp. 100–107, 2013.
• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM- 5), American Psychiatric Association, Arlington, Va, USA, 2013. • S. Penckofer, J. Kouba, M. Byrn, and C. E. Ferrans, “Vitamin D and depression: where is all the sunshine,” Issues in Mental Health Nursing, vol. 31, no. 6, pp. 385–393, 2010.
• D. C. Kerr, D. T. Zava, W. T. Piper, S. R. Saturn, B. Frei, and A. F. Gombart, “Associations between vitamin D levels and depressive symptoms in healthy young adult women,” Psychiatry Research, vol. 227, no. 1, pp. 46–51, 2015.
• M. Kjærgaard, K. Waterloo, C. E. A. Wang et al., “Effect of vitamin D supplement on depression scores in people with low levels of serum 25-hydroxyvitamin D: nested case-control study and randomised clinical trial,” British Journal of Psychiatry, vol. 201, no. 5, pp. 360–368, 2012.
• Rohan KJ, Meyerhoff J, Ho SY, Evans M, Postolache TT, and Vacek PM. Outcomes One and Two Winters Following Cognitive- Behavioral Therapy of Light Therapy for Seasonal Affective Disorder. The American Journal of Psychiatry. 2015.
