Fall is in the air! For some, this is a beautiful time of year filled with outdoor activities and enjoyment of the foliage and colors. It is also the advent of football season. Fall is often a very productive and structured time of year with soccer practices, getting back into the routines of school and work and other activities.
For others, though, it is a dreaded time of year, one heralding the black death of winter. As the days get shorter, some people notice a declining mood. Symptoms are different depending on the season of onset. For those with depression which has its onset in Fall or Winter, symptoms generally include fatigue, depression, crying spells, loss of interest in activities previously enjoyed, decreased concentration, decreased motivation/activity level, sleep problems (often oversleeping), decreased sex drive and carbohydrate craving/overeating.
First described in 1985, Seasonal Affective Disorder (as it is commonly called) seems to have increasing prevalence in those living farther from the equator. In the United States, there is thought to be an incidence of about 5% of adults with up to 20% of people having symptoms insufficient to make the actual diagnosis. It is a serious problem and can lead to dysfunction at home, school and/or work, suicidal thinking, social isolation and substance abuse/dependence.
According to the DSM-IV, this type of depression is called Major Depression with Seasonal Pattern. Most often, the depression occurs during the Fall and Winter (though it can also occur during other seasons including Summer). The distinguishing hallmark is that depressive episodes tend to recur around the same time of the year with complete remission the rest of the year. Diagnosis involves meeting criteria for Major Depression and the pattern must have occurred at least two years.
The cause is largely unknown at present. It does appear that the reduced level of sunlight in the Fall and Winter play a role, likely disrupting circadian rhythm and reducing melatonin and serotonin levels, which can affect sleep and cause depression. Seasonal changes in dopamine levels have also been found. Dopamine is a chemical messenger involved in motivation, pleasure, movement and learning. Genetics likely play a role as risk increases with family history of seasonal depression. It tends to be four times more common in females, but males who develop the condition are thought to have a more severe form. Also, low levels of Vitamin D have been associated with a higher occurrence of Seasonal Depression (and also other forms of depression).
Treatment of Seasonal Depression is generally thought to include Cognitive Behavioral Therapy (CBT), Phototherapy and Antidepressants. CBT is a therapy that essentially helps patients to see the connection between thoughts, feelings and behaviors. Phototherapy, also called Light Therapy, is essentially in the form of a light box, commercially available in many places (www.alaskanorthernlights.com has a good reputation). This light is about 25 times as bright as normal indoor light. Phototherapy is simple to administer as patients typically sit in front of a light box for 15-30 minutes once or twice a day. If finances allow, vacationing in a sunny spot will also provide the same benefits. Patients should be encouraged to get outside daily as well. Antidepressant treatment with Wellbutrin and many of the SSRI’s have been used with good results.
Once the seasonal pattern is identified, many patients can benefit from either starting or increasing antidepressant therapies (including medication and other types of therapies) prior to the typical onset of depression. Patients who employ a combination of treatments tend to do better. They should also work on self-care and stress management to mitigate the impact of depression. Some alternative therapies have shown to be beneficial in some cases, including acupuncture, which may be especially beneficial for pregnant women for whom medications present more risk. Exercise has also shown to be of benefit as has socialization but studies are limited in these latter treatments.
Jen Wisdom-Schepers, MD, practices psychiatry with Mountain States Medical Group in Johnson City.
2 Professional Park Drive, Suite 15 • Johnson City, TN 37604 • Phone: 423.979.0567 ª Fax: 423.979.0569