Right now, mid-December, if you happen to be sitting in a room with five of your friends, the odds are strong that one of you has seasonal affective disorder, or SAD. If you’re the one, you’re probably in your 20s or early 30s (the vulnerable years for SAD, though you can have it at any age), you know something’s wrong, and you know you’ve been dreading winter more with each passing year. Then again, you may never have connected your symptoms with either winter or the increased number of dark hours it brings.
If you have SAD, it’s a safe bet you’re a woman, like a majority of SAD sufferers. You may have heard of something called the winter blues, but you’re thinking, “This is more than the blues. I feel really awful!” If you tried discussing your symptoms with your doctor, know this: surveys of physicians show a remarkable lack of awareness about SAD. Your doctor may have recommended an antidepressant, but, fearing side effects, you never filled the prescription.
The three most common symptoms of SAD are depression, anxiety, and panic attacks. If you’ve suffered with these during the bright sunny days of summer and are already on medication, you probably discovered that by mid-December everything’s getting worse and you may wonder if you need your dose increased.
Other symptoms of SAD include:
• An overall lack of energy even for everyday tasks. “Do I have chronic fatigue syndrome?” “All I want to do after work is go to bed.”
• A weakened immune system. “I get one cold after another.” “Cuts take forever to heal.” “My candida is back!”
• Irritability. “I want to bite the head off my boyfriend and I think, ‘This isn’t me! THIS ISN’T ME!’”
• Lack of concentration. “I just stare at the TV.” “I can’t read a book anymore.” “I’m missing appointments and deadlines.”
• Overeating, carb cravings, and weight gain. “Do you know what it’s like to gain a pound a week?!”
• Alcohol and other drug use/abuse. “I know I’m drinking too much when I get home from work.”
• Feelings of guilt and worry. “Something’s wrong. I’m thinking about my health too much.” “I’m really worried about my life.”
• Sleep problems. “I haven’t felt refreshed in the morning in weeks.”
• Reduced sex drive. “There’s nothing. I feel nothing.”
If you have SAD, it’s possible you’ve had a history of depression or anxiety, or that one of these runs in your family. People with SAD often endure symptoms for two or three years before being diagnosed and learning about treatment.
According to the Cleveland Clinic, approximately 500,000 people in the US have SAD, and at least 10 to 20% of the US population suffer from the disorder to a greater or lesser degree. SAD can begin at any age but commonly starts around age 21, peaking throughout your 20s. At that point it seems to relent…or people who have it simply learn coping skills. Because SAD is one of several low-serotonin disorders, there’s a second peak during pre-menopause and the menopause years. This occurs because serotonin levels are closely linked to estrogen levels, and as estrogen heads south during menopause so does a woman’s stress-buffering serotonin.
Here’s what’s happening in SAD
As light enters your eyes, falling on your retina, your serotonin rises. The SSRI antidepressants (like Prozac) raise serotonin as well, so sunshine is indeed a lot like Prozac. Conversely, the darkness of short, overcast winter days reduces serotonin production–Prozac in reverse, so to speak—rendering you susceptible to SAD.
But there’s more. The same light that boosts serotonin also stimulates the hypothalamus, deep in your brain, which controls sleep, appetite, sex drive, temperature, mood, and physical activity. This occurs because your hypothalamus rules the pituitary, the master gland controlling your adrenal glands, thyroid, and ovaries.
In winter, with insufficient light, the functions of these three glands slow down. This is extremely useful if you happen to be a hibernating bear, however, if you’re a twenty-something woman, you may require quite a bit of light for your body to function normally. Without it, you’ll be in the group developing SAD symptoms
And even more! Enter the pineal gland. Research has also found that people with SAD, compared to people who don’t have the condition, produce higher levels of the sleep-inducing hormone melatonin in winter. The pineal, a tiny gland about the size of a grain of rice nestled deep in your brain, produces melatonin in response to being in the dark. When your melatonin levels rise, you feel sleepy.
As an aside, synthetic melatonin is readily available over-the-counter as a sleep aid, working dramatically well for some people who probably have sluggish pineal glands, but doing absolutely nothing for others. No one is really sure why this occurs. Interestingly, some people sleep really deeply when they wear a sleep mask, likely an effect of the total darkness enhancing their melatonin production.
When you’re exposed to light, as you are in the morning, melatonin levels fall and you wake up. Light also raises serotonin, and likely it’s the combination of rising serotonin and falling melatonin that causes many people to feel better during the summer months and worse in winter. These physiologic responses to light are also behind the usefulness of full-spectrum light boxes as the best known treatment for SAD.
Many people with SAD find they have specific triggers. Because serotonin is your stress buffer, any form of stress capable of overwhelming your buffering system can trigger SAD symptoms. These stressors include the usual culprits like traumatic life events (a relationship break-up, a job loss) and physical illness.
Another such stressor is disruption of your body clock. If you have difficulty setting your body’s circadian rhythm to daylight hours you can fall victim to SAD. An example: someone with a circadian rhythm disorder keeps going to bed later and later, and sleeping later as well. The college student who stays up until 3 am and can’t make any class before noon sets the stage for this disorder. Then, when school is over, she can’t get back on a normal schedule. Mixing up day and night is quite stressful on her body and she’ll be a good candidate for SAD as she sleeps through the few daylight hours that are left in wintertime.
SAD is a perfect storm of neurotransmitter and hormone hell.
• First, you’re a woman whose genetics render you a low-serotonin person with a compromised stress-buffering system.
• Second, your already low serotonin drops further in the dim light of winter.
• Third, your pineal gland, sensing darkness, pumps out more melatonin, making your main form of speech a yawn.
• Fourth, receiving little bright light to stimulate it, your sluggish hypothalamus slows your pituitary, adrenal, thyroid, and ovarian hormone function.
• And finally, stress from just about anything, including the stress of wondering what’s happening to your mind and body, throws you over the proverbial edge.
All these physiologic changes would be just fine if you could, like a bear, go into hibernation. But you can’t. You’ve got to be in the office on Monday. (By the way, if you happened to awaken our hibernating bear prematurely, he’d likely have each and every symptom of SAD, including anger management issues.)
Treatment
The very best treatment for SAD is light therapy from a full-spectrum lightbox or spending the winter in the Florida Keys or locations farther south. That’s because light raises serotonin, reduces melatonin, and jump-starts your hypothalamic-pituitary-adrenal+thyroid+ovary axis.
Light therapy is effective for 85% of people with SAD and works best if you expose yourself for about two hours, ideally in the morning or early afternoon. Using a lightbox in the evening will lower your melatonin so much that you might find yourself unable to sleep. Along with the lightbox, I also suggest sleeping with a sleep mask to further increase nighttime melatonin levels and force your brain into a healthy circadian rhythm.
But light therapy isn’t the only treatment for SAD. To deal with stress triggers, you might benefit from talk therapy such as counseling, psychotherapy, or cognitive behavior therapy (CBT). Here’s a further to-do list for the many (many!) of you with SAD:
• Get outside every day, even when it’s cold. If the sun is shining, stay out longer. When you’re outside, avoid sunglasses for at least 30 minutes.
• Move your work area near a window.
• Keep curtains and window blinds open throughout the day to let light in.
• Walk briskly every day and do other types of exercise, such as lifting weights, several times a week. Do as much of your routine as possible outside or near a window.
• Avoid going from one indoor space to another without getting a little sunlight. Going from house to car to mall to home or from home to subway to office to subway and back home has you living like a mole. At each transfer point, stay outside for awhile in the light. Better yet, walk part of the distance.
• Carbohydrates will raise your serotonin, but don’t capitulate to the Ho-Hos. Have plenty of fresh fruit and veggies throughout your day and also some good whole grains–half a cup of oatmeal in the morning, half a cup of kidney bean salad at lunch, and half a cup of brown rice with dinner.
• Replace home light bulbs with full-spectrum bulbs, available in any hardware store
• Low levels of vitamin D are linked to all sorts of health problems, including susceptibility to flu, so take at least 2,000 IU of vitamin D daily. Levels of vitamin D plummet in wintertime because of reduced sunlight in contact with your skin.
• If you feel yourself slipping into mild depression or increased anxiety, consider St. John’s wort, 450 mg twice daily. It will raise your serotonin virtually without side effects. Don’t try it if you’re taking an antidepressant, though. Too much serotonin could result.
• If SAD is a regular event in your life, rent or purchase a full spectrum light box. Contact the WholeHealth Chicago Apothecary for details on rental or purchase.
• Budget a winter vacation if possible. Even ski resorts are sunnier than Chicago.
If you feel truly overwhelmed by SAD, don’t reflexively refuse a prescription antidepressant like Lexapro or Celexa. These can raise your serotonin quite quickly and, if you know you do best in summertime, can be discontinued (with your physician’s supervision) when clocks are set to Daylight Savings Time.
We have many patients in our practice who know their bodies so well they simply send me an email to renew their antidepressants with a line like “Hey, it’s September. I feel my SAD coming on. Would you mind calling CVS for a refill?”
Be well,
David Edelberg, MD