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Seasonal Affective DisorderSeasonal Affective Disorder

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U-M Depression Center and Ann Arbor U-M Depression Center and Ann Arbor Public LibraryPublic Library Presentation on topics of interest relevant to Presentation on topics of interest relevant to

mental health in communitymental health in community Panel of experts from U-M Depression Center Panel of experts from U-M Depression Center

and Professionals in communityand Professionals in community Q/A formatQ/A format

Improve community awareness of resources Improve community awareness of resources available.available.

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Seasonal Affective DisorderSeasonal Affective Disorder

What is Seasonal Affective Disorder - SADWhat is Seasonal Affective Disorder - SAD The formal “Diagnosed” syndromeThe formal “Diagnosed” syndrome Sub-syndromal SADSub-syndromal SAD

Hypotheses surrounding SADHypotheses surrounding SAD Research relevant to SADResearch relevant to SAD

Treatment optionsTreatment options Physical TreatmentsPhysical Treatments MedicationMedication

Panel DiscussionPanel Discussion

Live in rooms full of lightAvoid heavy food Be moderate in the drinking of wine Take massage, baths, exercise, and gymnastics Fight insomnia with gentle rocking or the sound of running water Change surroundings and take long journeys Strictly avoid frightening ideas Indulge in cheerful conversation and amusements Listen to music.

Cornelius Celsus (first century AD)

On the treatment of disorders of mood…….

What is SAD?What is SAD?

SAD = Seasonal Affective DisorderSAD = Seasonal Affective Disorder Affective Disorder that occurs predictably at a Affective Disorder that occurs predictably at a

specific season - most frequently in the fall or specific season - most frequently in the fall or winter months.winter months.

““Affective Disorder” is used interchangeably Affective Disorder” is used interchangeably with “Mood Disorder” and usually refers to with “Mood Disorder” and usually refers to depression. depression.

Understanding Affective Understanding Affective DisordersDisorders

Kraepelin proposed Kraepelin proposed affect to consist of 3 affect to consist of 3 componentscomponents VolitionVolition

Energy & DriveEnergy & Drive

EmotionEmotion Happy / SadHappy / Sad

IntellectIntellect Rate of thoughtsRate of thoughts Content of thoughtsContent of thoughts

Affect - Affection

Volition – the drive to care for our offspring

Emotion – the love for our children

Intellect – the thoughts & speech related to our interactions with family and loved ones

Normal Affect

Volition

Emotion

Intellect

- Moods and disposition fluctuate over time

VolitionEmotion

Intellect

Depression

5

0

10

Mania

Volition

Emotion

Intellect

Affect and Affective DisordersAffect and Affective Disorders

Volition Volition – drives – energy levels– drives – energy levels Depression - lowered Depression - lowered

EmotionEmotion – mood (happy vs sad) – mood (happy vs sad) Depression – sad – low – guiltDepression – sad – low – guilt

IntellectIntellect – thinking – thinking Depression – decreased rate - negative Depression – decreased rate - negative

SAD - clinical features SAD - clinical features

Clinicians refer to “atypical depressive sx’s”Clinicians refer to “atypical depressive sx’s”

Sleep: hypersomnia - too much sleepSleep: hypersomnia - too much sleep Difficulty getting out of bedDifficulty getting out of bed Slow to “get going”Slow to “get going” Fatigued throughout the dayFatigued throughout the day

““AtypicalAtypical” because majority of depressed patients ” because majority of depressed patients experience difficulties sleeping (frequent awakenings experience difficulties sleeping (frequent awakenings during the night or awakening more that 1 or 2 hours during the night or awakening more that 1 or 2 hours earlier than custom). earlier than custom).

SAD - “atypical” featuresSAD - “atypical” features

Appetite Increase (hyperphagia)Appetite Increase (hyperphagia) Carbohydrate cravingCarbohydrate craving Comfort eating / grazingComfort eating / grazing Eating at non-meal timesEating at non-meal times

““AtypicalAtypical” because most people with ” because most people with depression experience decrease in depression experience decrease in appetite.appetite.

Sub-syndromal SADSub-syndromal SAD

““Winter Blues” - “Winter Doldrums”Winter Blues” - “Winter Doldrums” Common: 10 - 25% of middle latitude populationCommon: 10 - 25% of middle latitude population

Defies a clear definition….Defies a clear definition…. Does not meet diagnostic criteria for Depression Does not meet diagnostic criteria for Depression

Milder form of SAD with distinct discomfort and Milder form of SAD with distinct discomfort and qualitative change in functioning (decrease) and qualitative change in functioning (decrease) and activity levelactivity level Slowed down / IrritableSlowed down / Irritable Some symptoms of atypical depression Some symptoms of atypical depression

Over-eating & Over-sleepingOver-eating & Over-sleeping

SAD - ResearchSAD - Research

Epidemiology:Epidemiology: SAD ~ 1-3%SAD ~ 1-3%

Sub-syndromal SAD (Winter Doldrums) ~25%Sub-syndromal SAD (Winter Doldrums) ~25% Chronic Course - ~40% with seasonal pattern at 10 Chronic Course - ~40% with seasonal pattern at 10

year follow-up; 40% became non-seasonal.year follow-up; 40% became non-seasonal. High association with eating, anxiety, and substance High association with eating, anxiety, and substance

abuse disorders. abuse disorders. Associated with higher latitudes.Associated with higher latitudes.

Middle latitudes (such as Michigan !) Middle latitudes (such as Michigan !) Extreme northern latitudes show lower frequencyExtreme northern latitudes show lower frequency

SAD ResearchSAD ResearchCircadian Rhythms Circadian Rhythms

Photoperiod hypothesis:Photoperiod hypothesis: The shorter winter photoperiod results in SAD.The shorter winter photoperiod results in SAD.

Northern latitudes, controverted findingsNorthern latitudes, controverted findings Melatonin secretion longer during winter in SAD Melatonin secretion longer during winter in SAD Artificial light treats SADArtificial light treats SAD

Phase-shift hypothesis:Phase-shift hypothesis: Phase delay of circadian rhythm relative to external Phase delay of circadian rhythm relative to external

clock; waking later into evening and arising later in clock; waking later into evening and arising later in morning. morning.

Light therapy in am causes phase advance - correcting Light therapy in am causes phase advance - correcting phase delay. phase delay.

SAD - GeneticsSAD - Genetics

Individuals with SAD frequently have family Individuals with SAD frequently have family history of Depression (2/3) or SAD (1/3). history of Depression (2/3) or SAD (1/3). Are there genetic variants that predispose to Are there genetic variants that predispose to

depression and SAD?depression and SAD?

Class of genes - “circadian clock genes” have Class of genes - “circadian clock genes” have shown association with SAD.shown association with SAD. Are there genetic variants of these “clock genes” Are there genetic variants of these “clock genes”

associated with SAD.associated with SAD. Preliminary evidence suggests this but not always replicated Preliminary evidence suggests this but not always replicated

in independent studies.in independent studies. No specific tests to diagnose SAD.No specific tests to diagnose SAD.

Controversies in SADControversies in SAD

Phase delay / advance studies of circadian Phase delay / advance studies of circadian rhythm require rigorous monitoring of body rhythm require rigorous monitoring of body chemicals, sleep EEGs, temp, etc.chemicals, sleep EEGs, temp, etc. Small numbers of individuals studied Small numbers of individuals studied Conclusions often conflictConclusions often conflict

Conflicting results of effects of light Conflicting results of effects of light therapy on phase change. therapy on phase change. Phase advance not always associated with Phase advance not always associated with

clinical improvement. clinical improvement.

SAD - treatmentSAD - treatment

Light therapyLight therapy 30 min per day30 min per day

Begin with AM lightBegin with AM light 10,000 Lux10,000 Lux Specialty light boxSpecialty light box

Medication….Medication…. Usually required for Usually required for

major depressionmajor depression with with seasonal patternseasonal pattern

(10 - 15% respond to (10 - 15% respond to light alone)light alone)

““Sub-syndromal” SADSub-syndromal” SAD

Light therapy alone often Light therapy alone often lifts the “winter-blues”lifts the “winter-blues”

Ok for individual to buy Ok for individual to buy box on own accord, buy box on own accord, buy from established from established company.company. Follow instructionsFollow instructions Consult physician if taking Consult physician if taking

medication.medication. Some medications cause Some medications cause

light sensitivity.light sensitivity.

• Any light box you buy should have been tested successfully in peer-reviewed clinical trials.

• The box should provide 10,000 lux of illumination at a comfortable sitting distance. Product specifications are often missing or unverified.

• Fluorescent lamps should have a smooth diffusing screen that filters out ultraviolet (UV) rays. UV rays are harmful to the eyes and skin.

• The lamps should give off white light rather than colored light. "Full spectrum" lamps and blue (or bluish) lamps provide no known therapeutic advantage.

• The light should be projected downward toward the eyes at an angle to minimize aversive visual glare.

• Smaller is not better: When using a compact light box, even small head movements

will take the eyes out of the therapeutic range of the light.

Center for Environmental Therapeutics - www.cet.org

Let there be light….

Review of studies 1975 - 2003Review of studies 1975 - 2003

20 studies reviewed 20 studies reviewed for efficacy of light for efficacy of light therapy in SAD.therapy in SAD.

Very strong effect-Very strong effect-size for light therapy size for light therapy SADSAD Non SAD depressionNon SAD depression

Golden et al, Am J Psych. 2005

Activity level improves using 4 weeks of Bright Lights

Side Effects of Bright LightSide Effects of Bright Light

Possibility of ….Possibility of …. Sleep disturbancesSleep disturbances IrritabilityIrritability HeadacheHeadache Eye irritationEye irritation

Marginal increase (but not significant) Marginal increase (but not significant) compared to control group. compared to control group.

SAD - ConclusionsSAD - Conclusions

SAD - refers to a seasonal pattern occuring in SAD - refers to a seasonal pattern occuring in individuals with major Depressionindividuals with major Depression Symptoms are often “atypical” Symptoms are often “atypical”

Increased appetite and over-sleepingIncreased appetite and over-sleeping

Sub-syndromal SAD is commonSub-syndromal SAD is common Noticeable qualitative change in functioningNoticeable qualitative change in functioning

Light therapy is useful in treatment of SAD Light therapy is useful in treatment of SAD Effects noticeable within 2 weeksEffects noticeable within 2 weeks

Difficult to establish routine of using light therapy….Difficult to establish routine of using light therapy….

Panel MembersPanel Members

John Greden, MDJohn Greden, MD University of MichiganUniversity of Michigan

Randy Nesse, MDRandy Nesse, MD University of MichiganUniversity of Michigan

Tom Zelnik, MDTom Zelnik, MD St Joseph’s Medical CenterSt Joseph’s Medical Center

Julie Kuebler, RN, NursePractionerJulie Kuebler, RN, NursePractioner University of MichiganUniversity of Michigan

Laura Nitzberg, LCSWLaura Nitzberg, LCSW University of MichiganUniversity of Michigan