Newsletter #34

January 3, 2003

BANISH WINTER BLUES

Treatment For Seasonal Affective Disorder

By Hyla Cass, MD

What Causes SAD? An accumulation of evidence confirms that the decreased sunlight portion of a 24

Hour period, or a photoperiod, is the culprit.

Every fall, like clockwork, Maureen {not her real name} went into an emotional slump. As she sat in my office one winter morning, this 38-year-old bookkeeper, a mother of two teenagers, complained that

Her body felt heavy and her brain stayed in low gear. Her usually manageable life was becoming too much to handle.

"I can't get up for work in the morning," she said. "I jump at the kids, seem to have no patience at all, and my mood is down in the dumps." Maureen further described feeling sluggish and withdrawn, craving sweet and starchy foods, gaining weight, and sleeping whenever and for as long as she could--all symptoms of seasonal affective disorder (SAD). This form of depression occurs with the decreased amount of sunlight that we get during the fall and winter. Maureen's mother and sister had the same problem, and her recollections of the winter in her childhood home were particularly gloomy.

Sound familiar? If so, you may also be one of the 10 million Americans with full-blown SAD. More than twice that many people experience less serious versions of this disorder.

An accumulation of evidence confirms that the decreased sunlight portion of a 24-hour period, or a photoperiod, is the culprit. In people prone to SAD, sunlight deprivation triggers biochemical changes in the brain, directed by the brain chemicals melatonin and serotonin, resulting in a disturbance in the natural cycles of the body, or circadian rhythms, that control sleeping, wakefulness, and hormone secretion. While everyone has lower brain serotonin levels in fall and winter, people with SAD appear to have a more pronounced problem with serotonin transmission.

Our internal biological clocks are synchronized to the 24-hour light-dark cycle, which allows us to stay alert in daylight and to grow sleepy as the sun begins to set. While this pattern worked well for Stone Age people, who could rest and regenerate during the dark night hours, the invention of the light bulb (and even earlier, the discovery of fire) has led us to run our lives counter to our inborn cycles. No longer living a primal life, we are called upon to function during hours of darkness. In fact, can you imagine the slowdown if in the late fall and winter everyone slept from darkness until daylight?

When the eyes transmit light energy along the optic nerve to the pineal gland, a sequence of events is triggered. This tiny, light-sensitive gland at the base of the brain produces the hormone melatonin, which helps regulate inner biological rhythms. The amount of light determines how much melatonin is actually released from the pineal and secreted into the bloodstream. The less light, the more melatonin is released.

As light disappears, melatonin release begins: This appears to play a role in triggering sleep and lowering body temperature. As the sun rises, melatonin release is slowed, body temperature rises, and we begin to awaken.

As the nights grow longer and more melatonin is present in the blood, the amount of time spent sleeping or felling sleepy increase, particularly in those vulnerable to SAD. A recent study suggests that elevated daytime blood levels of melatonin might characterize those who are vulnerable.

Like bears who hibernate in the winter, humans also respond to seasonal rhythms. Except for accompanying emotional symptoms, SAD sufferers often seem to be in hibernation mode during the cold, dark months. Then once spring and sunlight arrive, they feel energetic and ready to get on with life.

Most people who experience SAD will become melancholy to the point of occasionally experiencing real grief. Others are more anxious or irritable than usual. Their irritability can be so extreme that violence may result. Other symptoms may include fatigue, depression, difficulty concentrating, social withdrawal, increased sensitivity to rejection, reduced activity, increased appetite, and reduced libido.

On a physical level, people suffering from SAD need at least an hour or two of extra sleep. They also feel a marked decrease in energy, with physical activity of almost any sort seeming to be "just too much." They also tend to overeat (especially carbohydrates) and gain weight.

For Maureen and other SAD patients, I prescribe exposure, from October through April, to a set of full-spectrum fluorescent lights (minus the ultraviolet, which can cause sunburn and increased risk of skin cancer) and 900 mg of St. John's wort every day. Effective relief is possible with daily exposure of 30 minutes at a light level of 10,000 lux (equal to early morning sunlight) of high-intensity, artificial sunlight. In a short time, Maureen soon found herself coming back to life, "as if spring had come in January." For the first winter in as long as she could remember, she was able to function as well as she did the rest of the year.

While my own clinical experience has shown that many people with less severe forms of SAD do quite well on St. John's wort (without the need for the lights), research shows an even stronger effect when the herbal and light therapies are combined. A 1994 study examined 20 patients with significant levels of depression associated with SAD. All the patients took 900 mg of St. John's wort extract (standardized at 0.3 percent hypericin) daily along with varying levels of light therapy. In 4 weeks, the group that received bright light (3,000 lux for two hours each day) showed a 72 percent drop in their depression scores, while the group treated with dim light (less than 3,000 lux) has a drop of 60 percent. Researchers concluded that St. John's wort is almost as effective as light therapy--for more convenient relief.

The B vitamins are also important, particularly B6, for maintaining adequate levels of neurotransmitters, especially serotonin. In addition, consider 5HTP (50 to 150 mg daily) to increase serotonin levels. Though we have no research to prove this, I have advised patients to use small amounts of melatonin for SAD. It appears that administration of melatonin at just the right time may shift the sleep-wake cycle enough to avoid daytime sleepiness. Take melatonin under the supervision of your healthcare professional.

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SAD affects approximately 5 percent of US adults, or some 10 million Americans. An estimated 25 percent of the population experiences some form of "winter blues," a less serious version of SAD. As with most forms of depression, the problem tends to tun in families and afflicts four times as many women as men. The farther north you live, the greater your risk. Studies show that only about one percent of Floridians suffer from SAD, compared to 10 percent of Alaskans.

• PMS. About one-third of women with PMS also have SAD, with increased weight gain and need for

• Shift work. Night workers are more susceptible to winter blues because they sleep during the day. Whether natural or artificial, bright light can improve alertness in night-shift workers, according to

• Bulimia nervosa. About one-third of patients with this disorder also have SAD, so they binge and purge more in fall and winter. Patients with bulimia often seek help in January. Light therapy rapidly improves mood plus eating and purging behavior among people with bulimia.

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If your "blues" are not serious enough to warrant bright light therapy, try one or more of the following:

1. Get as much light into your home as possible.
2. Take a long walk outdoors every day. For minor winter blues, this may be all that's necessary.
3. Seek help when you need it. If you feel yourself getting more depressed, don't be afraid to contact a

professional. Depression can be a serious disorder.

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SELECTED SOURCES

"Bright Light Treatment of Winter Depression: A Placebo-Controlled Trial" by Charmane I. Eastman

"Hypericum in Seasonal Affective Disorder (SAD)" by D. Wheatley

"Natural Bright Light Exposure in the Summer and Winter…" by J. Guillemette

Physical Exercise or Bright Light" by B.B. Pinchasov

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