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Sadness or Depression?

Separating Your Rhythms from the Blues:Normal Moods and Seasonal Depression

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About “10% of the US population” experience “some form of

Seasonal Affective Disorder (SAD)” but “only one or two percent of

people experience symptoms severe enough to warrant medical care

U.S. Department of Health and Human Services regards the

“Winter Blues” as “a general term, not a medical diagnosis,” “fairly common” and “more mild than serious.”

Winter Blues are known to usually clear up on their own

“Winter Blues” are often linked to specific things, such as “stressful holidays,

reminders of absent loved ones” or even slight symptoms of SAD that do not fully develop (News in Health).

SAD “Winter Blues”

7.2% 20.2 %

6.1% 17.1%

5.0% 13.9%

3.9% 10.6%

2.8% 7.5%

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People living at higher latitudes have shorter days in the winter and

report more seasonal depression and more winter blues

Appear similar, but not major depression

Avoid the “Where’s Waldo” Diagnostic Method

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Separating Your Rhythms from the Blues:Normal Moods and Seasonal Depression

Making sense of complexityMood 101

Basic Questions /Vocabulary

What is Mood ?

What is Normal Mood ?

What is Abnormal Mood ?

What is a Mood Disorder ?

How are Mood Disorders Diagnosed ?

What is Mood ?

Affect vs Mood

•Subjective feeling state

•Experience reported

•Long Lasting

•Objective feeling state

•Experience observed

•Variable overs seconds

Like the Weather Like the Climate

Normal Mood is

• Reactive to events with

–Amplitude

–Duration

–Direction

appropriate to the meaning of the event for that individual

Understanding Abnormal Mood states:

Depression:

Diminished ability to

respond positively to

pleasurable events

Mania:

Diminished ability to

respond appropriately

to negative events

What is Depression?

Slowed Speechor Movement

Agitation

Distractibility

Decreased Concentration

Excessive Guilt

Low Self Esteem

Depressed Mood

Diminished Interest in

Pleasurable Activities

AppetiteIncrease orDecrease

SuicidalIdeation

Sleep disturbanceIncrease orDecrease

Diagnosing Clinical Depression

Plus

Constellationof associated symptoms

AbnormalMood state

Decreased EnergyFatigue

Requires 5 symptoms present to a significant degree

nearly every day during a two week period

Diagnosing Clinical Major DepressionMDE

Requirement

≥ 5

DSM 5 Criteria

Present to a significant degree nearly

every day during a two week period

Abnormal mood

state

≥ 1

Depressed Mood

Decreased interest/ diminished pleasure

+ +

Associated

Symptoms

Sleep Disturbance

Low Self Esteem/Guilty

Decrease energy/Fatigue

Concentration difficulty

Appetite Disturbance

Psychomotor agitation/retardation

Suicidal ideation/morbid thinking

Seasonal Affective Disorder specifies a pattern in DSM 5

Episodes meet full criteria for major depression

and

• Coincide with specific seasons (appear in winter or summer months) for at least 2 years.

• Seasonal depressions must be much more frequent than any non-seasonal depressions.

Winter Summer•Low energy

•Hypersomnia

•Overeating

•Weight gain

•Craving for carbohydrates

•Social withdrawal (feel like “hibernating”)

•Poor appetite with associated weight loss•Insomnia•Agitation•Restlessness•Anxiety•Episodes of violent behavior

Most Common Symptom Pattern of SAD

CZ001060-SERO, March 200915

• Genes

• Environment

• Stress

• Social defeat

• Neurotransmitters

• Receptors

• Transporters

• 2nd messengers

• Oxidative stress

• Cytokines

Putative Causes of Mood Disorders

• Nutrition

• Mitochondrial dysfunction

• Circadian disruption

• Decreased neuropil

• HPA axis dysfunction

• Disconnection syndrome

• Cognition

• Temperament

• Nonadherence

CZ001060-SERO, March 2009

Understanding Circadian Rhythms

Light is a potent zeitgeber (time giver)

Zeitgebers: Tell the brain’s clock (suprachiasmatic nucleus) what time it is

Entrained: Snychronized Rhythm (same cycle length )

“Entrained”by Zeitgeberto 24 hr cycle

“Free Running”No Zeitgeber

25 hr cycle

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Day 10

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

Fall sleep Wake-up

Rhythms with common cycle length = Synchronized

“Un-entrained”Desynchronized

e.g. 24 hr and 30 hr cycles

Un-entrained“Free Running”Desynchronized

e.g. 25 hr and 27 hr cycles

Day 1

Day 2

Day 3

Day 4

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

* TMin

Fall sleep Wake-up

Day 7

Rhythms with different cycle length drift = Desynchronized

Entrained: Snychronized Rhythm (same cycle length )

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Entrained RhythmsYour Body’s Many Separate Organs Function like an Orchestra

Synchrony maintained byFollowing the same biological clock

Entrained Rhythms

Getting through the season

Self-management strategiesto help stabilize circadian rhythms

Re- enforce your Zeitgebers• Good sleep hygiene• Intentionally couple activity with your sleep

wake cycle• Manage light exposure• Honor social routinesCommon sense consumptionMeasure what you want to manage

• Sleep• Weight• Activity• Mood

Transform Your Engagement into Guidance

Put more into your care→ get more out

Give yourself the gift of Measure-based Guidance

at no cost

Create and Share Pre-assessment Reports

1. Visit: EngagedPractice.com2. Enter access code: engage2

A service provided by Collaborative Care Initiative

Engaged Practice Work Flow: Formal Measures Tab*

*This is an example of software that can aid in patient assessment. There are other similar software available.

DSM, Diagnostic and Statistical Manual of Mental Disorders; MADRS, Montgomery-Asberg Depression Rating Scale; PHQ-9, The Patient Health Questionnaire; QLESQ, Quality of Life Enjoyment Questionnaire; YMRS, Young Mania Rating Scale.

AT A GLANCE VIEW: REPORT 04/22/2016MADRS items Score

Reported Sadness 4

Observed Sadness 4

Inner Tension 6

Reduced Sleep 2

Reduced Appetite 3

Conc Difficulties 5

Lassitude 4

Inability to feel 5

Pessimistic Thoughts 4

SI/ Morbid Thoughts 2

MADRS total 39

YMRS items Score

Elevated Mood 2

Energy 3

Sexual Interest 0

Decreased need for sleep

1

Irritability 0

Speech 0

Language/thought process

0

Thought content 4

Disruptive/ Aggressive 0

Appearance 1

Insight 2

YMRS total 13

Self Reported items Score

Sleep 0

Ability to enjoy pleasant things/usual activities

-1.5

Self confidence/ Self Esteem -1.5

Energy -1. 5

Ability to concentrate -2.0

Distractibility 2.0

Appetite -.25

Physical restlessness/ agitation

1.5

Rate of movement or rate of speech

-1.5

Feel life isn’t worth living or suicidal thoughts

0

Talking -1.5

Racing Thoughts 0

Making plans or getting new projects started

-2.0

Behavior others regard as excessive, foolish or risky

0

PHQ-9 total 19

Q-LES-Q items Score

Physical Health 5

Mood 1

Work 1

Household Activities 2

Social Relationships 2

Family Relationships 4

Leisure Activities 2

Ability to Function 1

Sex drive and interest 1

Economic status 2

Living/Housing situation 2

Ability to get around physically

5

Vision in terms of ability to do work or hobbies

2

Overall sense of well being 2

Medication 2

Overall satisfaction and contentment

2

Q-LES-Q total 32.1%

DSM Graphic View Measure SummaryDSM Sensitive/Specific

Engaged Practice Work Flow: Formal Measures Tab*

Conc decision, concentration decision; Decr sleep, decreased sleep; Dep mood, depressed mood; DSM, Diagnostic and Statistical Manual of Mental Disorders; elev mood, elevated mood; FOI/RT, flight of ideas or racing thoughts; Guilt Dec SE, guilt or decreased self-esteem; Incr goal active, increased goal activities; Incr SE, increased self-esteem; MADRS, Montgomery-Asberg Depression Rating Scale; psychomotor agit, psychomotor agitation; SI morbid, suicidal ideation or

*This is an example of software that can aid in patient assessment. There are other similar software available.

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Instant Training: Visual Screening for MDE*

Review process:*Count the criteria

with bars reaching DSM threshold:

• Most Sensitive: ≥ 5 • Most Specific: ≥ 5 with both bars

• Other: ≥ 5 of one source

Measure what you want to manageEngaged Practice : Formal Measures*

* This is an example of software that can aid in patient assessment. There are other similar software available.MADRS, Montgomery-Asberg Depression Rating Scale; QLESQ, Quality of Life Enjoyment Questionnaire; STEP-BD, Systematic Treatment Enhancement Program for Bipolar Disorder; Wk, week; YMRS, Young Mania Rating Scale.

Strengthening your Zietgebers

A novel Mechanism of Action

can be attractive

Mechanism of Action

Be cautious with new antidepressant treatments (Especially those without FDA Approval)

Light Visors

Light Boxes

Dawn Simulators

None have FDA Approval for treatment of depression

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Light Source

Pragmatics of Bright Light Treatment

-Light SourceIntensity: > 5000 Lux (1 Lux = light from 1 candle at 1 meter)

Spectrum: Full spectrum (white) preferable (not red or infrared, not incandescent)

-Distance: ≈ 1 meter (should be able to put your palm on the center of source)

-Position: Direct to eye (do not stare at source)

-Timing: Consistent time each day (morning may be best)

-Duration: 15-30 minutes

TIMING MATTERS ONLY AT THE START

INITIAL EXPOSURES: PHASE DEPENDENT SHIFTREPEATED EXPOSURES: NO FURTHER SHIFT ESTABLISH ZIETGEBER

1. Get a lot of natural, bright light during the day.

2. Maximize darkness around bedtime and during sleep• Avoid trolling through social media before bed• Use your cell phone’s “night shift” setting

“Paleo Lighting”

Links to Resources

Light Products • The Sunbox Company

• Sunbox.com• 800.548.3968

• Northern light Technologies• northernlighttechnologies.com• 800-263-0066

Mood MeasuresCollaborative Care Initiative

EngagedPractice.com (access code: engage2) FreeDBSA Wellness Tracker Free

DBSAlliance.org/site/PageServer?pagename=wellness_tracker

Activity and Sleep Monitoring Apps• Fitbit• Nokia Healthmate Free

Call 1.800.548.3968Call 1.800.548.3968

Call 1.800.548.3968

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Conclusion

• Recognize normal variation• Maintain your rhythms• Measure what you want to manage• If in doubt contact your doctor