What doctors wish patients knew about seasonal affective disorder

AMA News Wire

What doctors wish patients knew about seasonal affective disorder

Nov 3, 2023

When the days grow shorter and temperatures drop, millions of people find themselves grappling with the “winter blues.” This is known as seasonal affective disorder, which is a form of depression that follows a seasonal pattern. Emerging primarily during the fall and winter months when sunlight exposure decreases and clocks fall back, seasonal affective disorder can take a toll on a person’s daily life. Knowing what to keep in mind and when to seek help can make all the difference during fall and winter months.

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The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, AMA member Adrian Jacques H. Ambrose, MD, MPH, a pediatric neurointerventional psychiatrist and senior medical director of the ColumbiaDoctors Psychiatry at Columbia University Medical Center, took time to discuss what patients need to know about seasonal affective disorder.

While this is “technically not a real name, seasonal affective disorder—or very appropriately initialized as SAD—is a subtype of major depressive disorder,” Dr. Ambrose said. “It’s characterized by recurrent episodes of depression that happen in a seasonal pattern, so generally when there is a reduced exposure to natural sunlight.”

“In the Northern hemisphere, it’s generally during the fall and winter months,” he said, noting “people historically have called it the winter blues. The official name from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published by the American Psychiatric Association, “is still just major depressive disorder and the subcategory is with seasonal pattern.”

Since seasonal affective disorder is “a subcategory of major depressive disorder, you see a lot of the common symptoms within the two categories,” Dr. Ambrose said. This includes “persistent sadness or low moods, and loss of interest or pleasure in activities.”

Additionally, “there’s a disruption in sleep patterns that are maladaptive—either you’re under sleeping or oversleeping, changes in your appetite and weight,” he said. “Oftentimes you see this trend for people to almost ‘hibernate,’ so there are increased cravings for carbohydrate rich foods and a lot of snacking.”

In turn, “people tend to gain more weight, have decreased energy and activity overall, and reports of fatigue and difficulty concentrating,” Dr. Ambrose said. “On the most intense and severe side, you have these increased feelings of the hopelessness, worthlessness and an increase in suicidality in extreme cases.

“So, it’s thought to be a depressive episode that’s triggered due to the disruption in the body’s natural circadian rhythm and the changes in neurotransmitter levels. And it’s less common in the summer months, but it can happen,” he added.

“It’s relatively common, depending on the severity of the individuals who may be experiencing seasonal affective disorder,” Dr. Ambrose said. “One of the reasons why they believe that it’s likely related to the reduced sunlight exposure during the winter months is because the prevalence of reported seasonal affective disorder tends to vary based on geographical location.

“So, in places where the days are generally shorter, it’s reported to have a higher prevalence,” he added, noting “you see places at higher latitudes like the Scandinavian countries there tends to be higher prevalence of seasonal affective disorders.”

“Some of the epidemiologic studies in the U.S. suggests that about 5% of adults will experience some version of seasonal affective disorder,” Dr. Ambrose said. “And the really interesting part is up to one in five additional U.S. adults will have some neurovegetative symptoms of seasonal affective disorder that may not fully meet the criteria for the full disorder. Instead of the full spectrum of symptoms, they’ll have some decreased energy.

“They may have some disruption of sleep and they may have some decreased concentration, but they may not necessarily have appetite changes. They may not necessarily have weight gain,” he added.

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While “we don’t fully know, some of the theories behind seasonal affective disorder or major depressive disorder with seasonal patterns is it’s linked to the reduced sunlight exposure and circadian rhythm disruption during the winter months,” Dr. Ambrose said.

Additionally, “it’s a combination of the circadian rhythm and the serotonergic and melatonin imbalance that we generally see during the shifting of the sunlight exposure because they both play really important roles in mood regulation and sleep,” he said. 

“Social isolation tends to coincide with a lot of the neurovegetative symptoms,” Dr. Ambrose said. That means “you have reduced interest or pleasure in activities and you have low energy and more fatigue.”

As a result, “you are more likely to socially isolate because you don’t want to do anything, you don’t want to interact with other people and it compounds on itself,” he said.

“Generally, the worst months—from incidental findings of patients in our ambulatory clinics—tend to be escalating around December, January, February,” Dr. Ambrose said. “And this is where I want to be mindful not to attribute anything, but some theories are this is when you have the least amount of daylight during the winter months.

“This is also when people are able to get care because the holidays and actually having some time off and you are around your family—there are more people to encourage you to get care,” he added. “If you think about right around December that’s when a lot of businesses close, so there’s an increased level of stress that people endure as well.”

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Seasonal affective disorder doesn’t just happen during winter months. It can also happen in the summer.

“In the literature, they’ve described this phenomenon: the summer seasonal affective disorder,” Dr. Ambrose said. “It’s much less common in comparison to the fall and winter, but the summer seasonal affective disorder we generally see more activating symptoms. So, more anxiety, more insomnia and worsened appetite.”

“This is where it’s very important to have this conversation with your psychiatrist because if you have this recurrent pattern—and the key here is the recurrent patterns of episodes because it could be a major depressive disorder—this is where treatment planning could be very helpful,” he said. “So, instead of waiting until you decompensate into a full-blown depressive episode, this is where you can work with your psychiatrist to proactively plan either engaging in augmenting treatment or managing your psychopharmacology to create some stabilization.”

“For the most part, the durations of the seasonal affective disorder symptoms can also vary if they are directly linked to this theory of decreased sunlight exposure or disruption in the regular circadian rhythm,” Dr. Ambrose said. “With appropriate treatment, oftentimes symptoms can resolve within weeks or months, but the caveat here is if you have depressive symptoms during the winter months, it doesn’t always mean that you have seasonal affective disorder.

“It could just be coincidentally that you have a major depressive disorder during the winter times,” he added. “I stress this because patients oftentimes will be really frustrated that they have a depressive episode during the winter months and it’s springtime and they still haven’t gotten better.”

That’s because “it may not necessarily be seasonal affective disorder,” Dr. Ambrose said. “The etiology, the root cause behind your symptoms, may not necessarily be the circadian rhythm changes or the reduced light exposure. In which case, having the days be longer in the spring may not be as helpful to you.”

Seasonal affective disorder “is diagnosed through conversations with your physician. As with any other psychiatric diagnosis, it’s through a comprehensive clinical evaluation by a psychiatrist,” Dr. Ambrose said. “And the reason I really want to underscore this for patients is because from the patient’s perspective it could just be seasonal affective disorder.”

“Oftentimes when I interview patients, I’ll find out that it’s actually compounded. Either there will be very atypical presentations or there’ll be additional comorbidities that a patient may not necessarily think about,” he said, noting “there are no specific laboratory tests for diagnosing seasonal affective disorder. It’s a clinical diagnosis.”

“I don’t want patients to stress out trying to figure out their own diagnosis. It’s more of how you work together with your physician so you can better understand any potential contributing factors, some clarity for your diagnosis and, most importantly, treatment planning,” Dr. Ambrose said.

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One of the more common methods for treating seasonal affective disorder “is using photo therapies or light therapy in which individuals are exposed to bright white lights,” Dr. Ambrose said, emphasizing “it has to be ‘white lights.’ It’s the natural light exposure that you theoretically would get and what you’re trying to do is to mirror the normal circadian rhythm that you typically would get.”

Additionally, “you would want to have this light exposure first thing in the morning. You don’t want to do it at night because that’s when it disrupts your sleep pattern,” he said. There is also “some evidence that cognitive behavioral therapy can really help patients throughout this period.”

“Some of the other non-pharmacologic interventions also are the traditional lifestyle adjustments that we often talk about,” Dr. Ambrose said. Those include “sleep hygiene, stress management, physical activity and exercise.”

Also, when possible, “increasing outdoor activities so you can maximize your exposure to natural daylight during the day,” he said.

“For medications or pharmacologic options, it’s typically a component of both,” Dr. Ambrose said. “For the most part that means the antidepressants. And in certain situations, vitamin D supplementation can be helpful for patients who struggle with seasonal affective disorder because it tends to run as a comorbid condition.”

“A lot of time, especially during the winter months, patients say they feel really tired, don’t have a lot of energy and have this really low mood,” he said. That’s when “I’ll often check the vitamin D level. Half the time it’s quite low.”

But it is important to “have this conversation with your psychiatrist because you don’t want to just randomly take vitamin D supplementation,” Dr. Ambrose said. “That can potentially be maladaptive and harmful if it builds up in your system over time.”

“As we begin to more proactively look at mental health as a medical condition with medical treatments, we can look at it in very similar ways as an annual physical,” Dr. Ambrose said.

For example, “having an annual psychiatric appointment in which you can address a lot of these longitudinal or recurrent symptoms or concerns with your psychiatrist in a way that we can more proactively or preemptively treat the symptoms before they become problematic,” he said.

“The challenge that I often hear from people is they have been struggling with this for three, four months and it breaks my heart because you didn’t need to suffer for that long,” Dr. Ambrose said. “My hope is that we can destigmatize mental health care and the conversations surrounding mental health.”