Seasonal Affective Disorder

1. Seasonal Affective Disorder Kenneth R. Yeager PhD

2. SAD Definition • Seasonal Affective Disorder (SAD) is a recurrent major depression which generally results in lethargy and depression symptoms during the Fall and Winter seasons • Measure with Global Seasonality Score (GSS) from the Seasonal Pattern Assessment Questionnaire (SPAQ). (Rosenthal, 1987) • Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (APA, 2000)

3. SAD Definition • Structured Interview Guide for the Hamilton Depression Rating Scale: Seasonal Affective Disorder Version (SIGH-SAD) (Williams, 1988) • WHO “ICD-10 Classification of Mental and Behavioral Disorders” (WHO, 1992) • SAD epidemiology favors age (young), gender (female), and latitude (far from equator), but not race or ethnicity (Sher, 2001; Boehnert, 2003; Magnusson, 2000; Eagles, 2003)

4. SAD Mechanisms • Melatonin Dysregulation(Malhotra, 2004; Arnedt, 2003; Lam, 2000; Wehr, 2001) • Secretion is longer than normal in winter • Serotonin Deficiency (Sher, 2001) • L-tryptophan is a precursor of serotonin • Genetic Abnormalities (Sher, 2004; Ebisawa, 2007) • Based on epidemiology studies; serotonin transporter or clock gene defects

5. Comorbidity • SAD also frequently found with • Bulimia nervosa (Levitan, 2004; Eagles, 2003) • Premenstrual dysphoric disorder (Portella, 2006) • Alcohol dependence (Sher, 2004) • No diurnal preference (morningnessvseveningness) (Natale, 2005; Bernert, 2005)

6. SAD Symptoms • A distinct seasonal pattern to your mood (i.e., very little or no depression symptoms during spring or summer months, when the days are longer) • A recurrent pattern of decreased energy and activity levels you usually enjoy during the winter months • Improved mood if you are in a sunnier climate during the usual "high risk" winter months

7. SAD Symptoms • Persistently low, depressed mood that lasts for usually two to three months during winter months. November to February are the peak months. • Depression symptoms such as: • low mood, • changes in appetite or weight, • decreased energy or fatigue, • sleep changes, • avoidance of social situations) in the absence of other identifiable triggers or causes

8. Reduce SAD Symptoms • There are a number of very effective strategies that can help lessen the impact of SAD: • Make a point to spend more time outdoors during peak light hours (10am to 2pm), even if it's only for 10 to 15 minutes during a coffee or lunch break. • Arrange your home and work environments (if possible) to maximize your exposure to direct sunlight: Leave blinds and curtains open and try to be around windows that allow in natural light.

9. Reduce SAD Symptoms • Avoid sedentary activities, turn off your television and stay off your couch • Engage in activities that while indoor engage your brain and body. It’s a great time to do a home project, work on that novel you have been planning to write, hone your music talents • Socialize, winter is a great time to reconnect with friends, host gatherings, visit relatives

10. Reduce SAD Symptoms • If you are going to be drinking while socializing remember all things in moderation. Too much alcohol can contribute to SAD symptoms. • The grey months are also a time for keeping up with vitamin supplements such as vitamin D, and other ammine boosting supplements to keep those winter sniffles at a distance

11. SAD Treatment • If you find the above listed strategies are not working for you consult your healthcare provider. They may make additional recommendations such as: • Light therapy (Wirz-Justice, 2005; Golden, 2005) • 2500 to 10,000 lux white light for 15-30 min • Wake therapy? Controlled sleep deprivation • SSRIs (Prozac, Zoloft) do as well as light (Blumberger, 2005)

12. Reduce SAD Symptoms • By vigilant about taking care of yourself in the fall and winter months, be sure you: • exercise, take walks outdoors between 10:00 am and 2:00 • eat a healthy diet • socialize • drink alcohol in moderation • consider vitamin supplements such as vitamin D

13. What is your gender? ___ M ___ F Are you above the age of 35 ___ Yes ___ No Have you ever been diagnosed with Seasonal Affective Disorder (SAD)? ___ Yes ___ No Have you ever been diagnosed with bulimia? ___ Yes ___ No Calculate Your Risk

14. Calculate Your Risk • Have you ever been diagnosed with premenstrual dysphoric disorder (severe PMS)? ___ Yes ___ No • Have you ever been diagnosed with an alcohol or drug problem? ___ Yes ___ No • Are you more sensitive to odors than others? ___ Yes ___ No • Does anyone in your immediate family have seasonal affective disorder? ___ Yes ___ No

15. Conclusion • The total risk value from this brief survey is a score of 8, it can help quantify the risk of having SAD. If you are female you can begin by adding 1 point • If you find your scores in the range of 1-3 you are experiencing usual seasonal blues. • If your score is 4-6 get moving and take your supplements • If your score is 7 or 8 ask your healthcare professional about Seasonal Affective Disorder.

16. References • (APA, 2000) American Psychiatric Association. (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IVTR). Washington, DC: American Psychiatric Press. • (Arendt, 2003) J. Arendt (2003) Importance and Relevance of Melatonin to Human Biological Rhythms. Journal of Neuroendocrinology, Vol. 15, 427–431. • (Barinaga, 2002) Marcia Barinaga (8 Feb 2002) Circadian Clock: How the Brain's Clock Gets Daily Enlightenment. Science Vol. 295. no. 5557, pp. 955–957. • (Bernert, 2005) Rebecca A. Bernert (2005) A Circadian Vulnerability For Depression: Eveningness And Sleep Variability. Master’s thesis for Florida State University. • (Bhatia, 2007) Subhash C. Bhatia, Shashi K. Bhatia. Diagnosis and Treatment of Premenstrual Dysphoric Disorder. Downloaded on 6/5/2007 from http://www.aafp.org/afp/20021001/1239.html.

17. References • (Bierman, 2005) Andrew Bierman, Terence R Klein and Mark S Rea (2005) The Daysimeter: a device for measuring optical radiation as a stimulus for the human circadian system. Meas. Sci. Technol. (16) 2292–2299. • (Blumberger, 2005) Daniel M. Blumberger, M.D., and Anthony J. Levitt (Oct 2005) The Light-er Side of Treating Seasonal Affective Disorder. Psychiatric Times Vol. 22 Issue 11. • (Boehnert, 2003) Caryl E. Boehnert, Robert A. Alberts (Jan 2003) Seasonal Affective Disorder in Women How to identify and treat. Women’s Health in Primary Care. Vol. 6, No. 1. • (Eagles, 2003) John M. Eagles (2003) Seasonal affective disorder. British Journal of Psychiatry 182, 174-176. • (Ebisawa, 2007) Takashi Ebisawa (2007) Circadian Rhythms in the CNS and Peripheral Clock Disorders: Human Sleep Disorders and Clock Genes. JPharmacol Sci 103, 150 – 154.

18. References • (Golden, 2005) Robert N. Golden, Bradley N. Gaynes, R. David Ekstrom, Robert M. Hamer, Frederick M. Jacobsen, Trisha Suppes, Katherine L. Wisner, Charles B. Nemeroff, (2005) The Efficacy of Light Therapy in the Treatment of Mood Disorders: A Review and Meta-Analysis of the Evidence. Am J Psychiatry; 162, 656–662. • (Horne, 1976) Horne, J.A., & Östberg, O. (1976). A self-assessment questionnaire to determine morningness-eveningness. International Journal of Chronobiology, 4, 97-110. • (Keller, 2004) Matthew C. Keller, Barbara L. Fredrickson, Oscar Ybarra, Stephane Cote, Kareem Johnson, Joe Mikels, Anne Conway, Tor Wager (2004) A Warm Heart and a Clear Head The Contingent Effects of Weather on Mood and Cognition. Psychological Science (16) 9, 724-731. • (Lam, 2000) Raymond W. Lam, Robert D. Levitan (2000) Pathophysiology of seasonal affective disorder: a review. J Psychiatry Neurosci 25(5) 469-80.

19. References • (Levitan, 2004) Robert D. Levitan, Mario Masellis, Vincenzo S. Basile, Raymond W. Lam, Allan S. Kaplan, Caroline Davis, Pierandrea Muglia, Bronwyn Mackenzie, Subi Tharmalingam, Sidney H. Kennedy, Fabio Macciardi, James L. Kennedy (2004) The Dopamine-4 Receptor Gene Associated with Binge Eating and Weight Gain in Women with Seasonal Affective Disorder: An Evolutionary Perspective. Biol Psychiatry 56:665–669. • (Lewy, 1989) Lewy, A.J., Sack, R.L., Singer, C.M., White, D.M., Hoban, T.M., 1989. Winter depression and the phase-shift hypothesis for bright light’s therapeutic effects: history theory and experimental evidence. In: Rosenthal, N.E., Blehar, M.C. (Eds.), Seasonal Affective Disorders and phototherapy. Guilford Press, New York, pp. 295–310. • (Lewy, 2006) Alfred J. Lewy, Bryan J. Lefler, Jonathan S. Emens, and Vance K. Bauer.(2006) The circadian basis of winter depression. PNAS; 103; 7414-7419. • (Magnusson, 2000) Magnusson A. (2000) An overview of epidemiological studies on seasonal affective disorder. Acta Psychiatr Scand 101: 176-184.

20. References • (Malhotra, 2004) Samir Malhotra, Girish Sawhney, Promila Pandhi (2004) The Therapeutic Potential of Melatonin: A Review of the Science. MedGenMed. 6 (2): 46. • (McCarthy, 2002) E. McCarthy, N. Tarrier, L. Gregg (2002) The nature and timing of seasonal affective symptoms and the influence of self-esteem and social support: a longitudinal prospective study. Psychological Medicine, 32, 1425–1434. • (Murray, 2006) Greg Murray, Erin E. Michalak, Anthony J. Levitt, Robert D. Levitan, Murray W. Enns, Rachel Morehouse, Raymond W. Lam. (2006) O sweet spot where art thou? Light treatment of Seasonal Affective Disorder and the circadian time of sleep. Journal of Affective Disorders (90) 227– 231. • (Natale, 2005) Vincenzo Natale, Ana Adan, Paolo Scapellato (2005) Are seasonality of mood and eveningness closely associated? Psychiatry Research (136) 51– 60.

21. References • (NINDS, 2007) National Institute of Neurological Disorders and Stroke, NINDS Hypersomnia Information Page, downloaded on 6/3/2007 from http://www.ninds.nih.gov/disorders/hypersomnia/hypersomnia.htm. • (Portella, 2006) Portella, Amy T. Nguyen; Haaga, David A. F.; Rohan, Kelly J. (Nov 2006) The Association Between Seasonal and Premenstrual Symptoms Is Continuous and Is Not Fully Accounted for by Depressive Symptoms. Journal of Nervous & Mental Disease. 194 (11) 833-837. • (Postolache, 2002) Postolache, TT, Wehr, TA, Doty, RL, Sher, L, Turner, EH, Bartko, JJ, Rosenthal, NE. (2002) Patients with Seasonal Affective Disorder have Lower Odor Detection Thresholds than Control Subjects. Arch Gen Psychiatry (59) 1119-1122. • (Rosenthal, 1984) Rosenthal, N.E., Sack, D.A., Gillin, C., Lewy, A.J., Goodwin, F.K., Davenport, Y., Mueller, P.S., Newsome, D.A., Wehr, T.A., 1984. Seasonal Affective Disorder: a description of the syndrome and preliminary findings with light therapy. Arch. Gen. Psychiatry 41, 72–80. • (Rosenthal, 1987) Rosenthal NE, Bradt GH, Wehr TA. Seasonal Pattern Assessment Questionnaire. Washington, DC: National Institute of Mental Health; 1987.

22. References • (Sher, 2001) Leo Sher (2001) Genetic Studies of Seasonal Affective Disorder and Seasonality. Comprehensive Psychiatry, Vol. 42, No. 2 (March/ April): pp 105-110. • (Sher, 2004) Leo Sher (Jan/Feb 2004) Alcoholism and Seasonal Affective Disorder. Comprehensive Psychiatry, Vol. 45, No. 1: pp 51-56. • (Terman, 2006) Michael Terman, Jiuan Su Terman (Dec 2006) Controlled Trial of Naturalistic Dawn Simulation and Negative Air Ionization for Seasonal Affective Disorder. Am J Psychiatry 163:2126-2133. • (Tsuno, 2005) Tsuno, N, Besset, A, Ritchie, K (2005) Sleep and Depression. J Clin Psychiatry (66) 1254-1269. • (Vieth, 2004) Reinhold Vieth, Samantha Kimball, Amanda Hu, Paul G Walfish (2004) Randomized comparison of the effects of the vitamin D3 adequate intake versus 100 mcg (4000 IU) per day on biochemical responses and the wellbeing of patients. Nutrition Journal, 3:8.

23. References • (Wehr, 2001) Wehr, TA, Duncan, WC Jr, Sher, L, Aeschbach, D, Schwartz, PJ, Turner, EH, Postolache, TT, Rosenthal, NE (2001) A Circadian Signal of Change of Season in Patients with Seasonal Affective Disorder. Arch Gen Psychiatry. (58) 1108-1114. • (WHO, 1992) World Health Organization. (1992) The ICD-10 Classification of Mental and Behavioral Disorders. Diagnostic Criteria for Research. Geneva, Switzerland: World Health Organization. • (Williams, 1988) Williams, J. B. W., Link, M. J., Rosenthal, N. E. & Terman, M. (1988) Structured Interview Guide for the Hamilton Depression Rating Scale: Seasonal Affective Disorder Version (SIGH-SAD) (New York State Psychiatric Institute, New York). • (Winkler, 2005) D. Winkler, S. Kasper. (2005) Seasonal affective disorder: from diagnosis to treatment. Medicographia, Vol 27, No. 3. • (Wirz-Justice, 2005) Anna Wirz-Justice, Francesco Benedetti, Mathias Berger, Raymond W. Lam, Klaus Martiny, Michael Terman, Joseph C. Wu (2005) Chronotherapeutics (light and wake therapy) in affective disorders. Psychological Medicine, 35, 939–944.