A New Approach to Treating Seasonal Affective Disorder

Seasonal affective disorder is a type of clinical depression that commonly occurs in the fall and winter months and typically resolves in the spring and summer. While it can take any seasonal pattern, the fall/winter type is overwhelmingly the most common. The only thing that makes it different from garden-variety depression is the seasonal pattern that it follows.

Because of their similarities, SAD is often misdiagnosed as depression. It sometimes takes a few years for people who have this pattern to recognize that it’s a pattern, and that it’s tied to the seasons.

Because we’re diagnosing depression when diagnosing SAD, we look for at least five of the nine diagnostic symptoms of depression. We’re diagnosing a depression that follows a seasonal pattern, meaning we’re looking for depressive symptoms that are present much of the day, almost every day, for at least two weeks. The hallmark symptoms of depression are:

1. Feeling consistently down for most of the day or nearly every day.

2. A loss of interest in the things that would have otherwise been enjoyable. These are things I consider natural antidepressants, such as social activities that previously would have brought a sense of enjoyment or pleasure.

3. Feeling overwhelmingly tired or experiencing low energy.

4. Inability to hold attention and focus or experiencing difficulty in concentrating.

5. Feeling worthless or hopeless.

6. Issues with sleep. Either too little or too much. In winter depression, we tend to see hypersomnia or sleeping too much. In most cases, the individual sleeps for at least an extra hour a day compared to the spring or summer. Some patients may sleep ten to even fourteen hours a day and are still tired. It’s not restorative sleep that we’re seeing. A minority of patients, on the other hand, experience insomnia.

7. Changes in appetite or weight. This could be either wanting to eat a lot more or a lot less than usual. In winter depression, it’s usually wanting to eat more, and it’s usually carbohydrate-rich foods. Either sugars, starches, or both. With this, we typically see weight gain with an increased appetite or weight loss with a decreased appetite.

8. Agitation often accompanied by feelings of guilt and shame.

9. In extreme cases, thoughts of death or suicide.

Individuals can be diagnosed with SAD when they’re experiencing five of these symptoms, which need to include the first and/or second symptom.

These are not momentary symptoms; rather, they are pervasive for at least a couple of weeks. On average, it’s estimated to be five months of the year in a major depressive episode. It’s a lot of time to spend in depression, in terms of the cumulative toll that it could take on a person’s life.

Similar to depression, there is a pronounced gender difference for those affected by SAD. Depression in general is two times more common in women than in men, and data suggests seasonal depression is even more common in women than in men. When we look at its prevalence, we’re looking at a single snapshot in time. And we’ve found that most cases occur in young adults, typically in their twenties to thirties. We’re not entirely sure why it occurs in this age range, though, since these studies don’t follow people over time. One theory is that SAD becomes less prevalent as people age, because they learn how to cope with it or possibly move to places that don’t have winters that are as harsh.

It’s estimated that up to 10 to 20 percent of recurrent depression cases follow a seasonal pattern. This is generally the course of depression, in which a depressive episode tends to return over time, with periods of time without depression between the episodes.

For SAD patients, there are unfortunately very few studies that have tried to look at the long-term trajectory of the disorder. So we don’t have a coherent idea of its outlook. We’ve tried contacting people we knew who had SAD in the past to learn about their experience and see where they’re at today, and we’ve found mixed long-term courses. A lot of them continue to experience SAD episodes every winter. Others become more subclinical, where they used to have full-threshold SAD, and now they may just have the winter blues. Some develop a completely nonseasonal course where they still have depressive episodes but it’s not tied to the seasons. And others fully remit, where they don’t have depression, seasonal or otherwise, moving forward.

In terms of how SAD differs from depression, there is a strong correlation of SAD with latitude in the United States. The farther you are from the equator, the more cases you’ll find. It is estimated that 9 percent of those people who live in Alaska suffer from SAD, compared with 1 percent of those who live in Florida. For most people—at least in the northern United States—SAD slowly begins in October. People often report an increase in their symptoms after the end of daylight saving time and experience their symptoms in full effect in January and February. It is in these two months that we find the largest proportion of SAD patients in a full major depressive episode.

Another strong link is photo period, or length of daylight. Photo period is the strongest predictor of when symptoms start in any given year for someone who has seasonal affective disorder, as well as how severe the symptoms are on a given day. The number of hours from dawn to dusk determines your photo period. We believe that photo period is what explains the onset of this disorder and can determine how bad symptoms may be on any particular day.

Light therapy was the first line of treatment developed specifically for SAD patients. It was developed at the National Institute of Mental Health under Norman Rosenthal. He was a psychiatrist who moved from South Africa to Bethesda, Maryland, to work at the National Institute of Mental Health, and he experienced SAD symptoms. He was interested in learning more about it, and seeing if others experienced similar symptoms. He put an ad in The Washington Post, asking whether anyone experienced depression in the fall and the winter, and the lab phone rang constantly for weeks at a time. They had a huge response from people who thought they had the symptoms. They brought them in, interviewed them, and published the first studies on the symptoms and the pattern it seemed to follow. From this, they developed light therapy as a form of treatment.

With light therapy, the goal is to give people a very bright dose of light, first thing in the morning, to simulate an early dawn. In theory, we’re trying to jump-start a sluggish biological clock, so that circadian rhythms go back to a normal phase as if they’re in the summer, when these people are feeling good. The devices tested in clinical trials are 10,000 LUX, which is the same intensity of light from the sky at sunrise. We block out the UV rays since they’re not necessary for an antidepressant response. We’ve found that prescribing patients to sit in front of 10,000 LUX for at least thirty minutes a day is what it takes for the treatment to be effective in people who have SAD. That said, similar to finding the right antidepressant, it can be a bit of a trial-and-error process. We try to find that sweet spot of exactly how many minutes a day and at what time or times of the day it’s most effective for the patient. The optimal benefit from light therapy must be determined on an individual basis so we can balance any side effects they may experience in response to the light.

The same drugs that are effective in treating nonseasonal depression—particularly SSRIs like fluoxetine/Prozac—have been tested for SAD with a good outcome in placebo-controlled studies. There is one drug that’s FDA-approved specifically to prevent SAD, which is Wellbutrin Extended Release. There was a large multisite study—with the GlaxoSmithKlein drug—completed a few years ago with over 1,000 SAD patients. The study compared putting people on the Wellbutrin Extended Release versus a placebo, and the participants started the treatment early in the fall when they weren’t yet having their symptoms, and the study followed them into the winter. The researchers found fewer relapses on the drug than with the placebo, which led to the FDA approval of the medication. Either bright-light therapy or antidepressant medication are typically used in treating SAD.

While I was writing and reviewing the studies done on CBT for depression, I had an idea to create a form of CBT tailored specifically to SAD patients. There is an extensive body of research demonstrating that CBT is an effective talk therapy for people with depression. There have also been a lot of clinical trials showing that it worked as well as antidepressant medications for improving depression. Additionally, when you follow people over time, after they’re treated to remission using CBT versus treated to remission using antidepressant medications, there are fewer relapses and recurrences among those treated with CBT than those treated with antidepressant medication.

I thought it would be useful if those results could be generalized to SAD since, by definition, it’s a recurrent form of depression. I thought we could teach people new ways of coping with the winter, focused on changing their thinking styles and behaviors, with the hope they would carry these new skills with them into the future to fortify against a relapse. That was my inspiration to explore the utility of this treatment.

The protocol entails twelve sessions, divided by cognitive or behavioral focus. Each session is an hour and a half, and it’s two sessions a week over the course of six weeks. I call it the Bootcamp CBT. Unlike traditional CBT used for depression, this protocol is tailored specifically to SAD. The attempt is to pack a lot of treatment into a short period of time. And for efficiency in the research, we’ve been running it in small groups of about six to eight SAD participants with a psychologist.

First, we focus on the behavioral sessions, in which we’re trying to get patients to be more proactive and active in their lives. We’re trying to identify pleasant activities someone can do in the wintertime. We often see a pattern where people go straight home after work, get under a blanket on the couch, watch TV and ruminate about how bad they feel, which breeds depression and is socially isolating. We ask people about fun things that they can fuse into their lives.

This changes the focus to what we can do instead of what we can’t do, since we know focusing on what we can’t do doesn’t work to improve the mood. It’s a creative process where we have to consider a lot of alternatives. Most times, we’re speaking to people who are extremely summer-focused. For example, when you ask someone with SAD what they enjoy doing, they’ll say things like going for a walk on the beach, having a backyard party, or watering the garden. All of these are great, but for the five months of the year when those things are not accessible, we have to find a substitute activity. We can instead view winter as a sanctuary of time. It could be seen as a time to learn something new, explore a new interest, take a class, join a group, or anything to get you actively involved in something during the day.

There’s a lot of negotiation in finding what activities could be pleasurable during the winter to give you a sense of enjoyment. We also work by trying to get people to take baby steps out of this hibernation mode. It could be as simple as first trying something for ten minutes a day to see how it goes. From there, we try to work up to build longer, pleasant activities.

For the cognitive sessions, we focus on challenging and changing negative thoughts. We try to have the individual understand their negative thoughts by writing them down in a thought log, or a thought diary, to begin to notice the relationship between having certain thoughts and feelings. We’re looking for things like negative self-talk or self-chatter that can lead to feelings of depression. A lot of these negative thoughts are specific to winter; for example, negative thoughts about how short the days are or negative thoughts about the bad weather.

To address these negative thoughts, we use the Socratic method. We look at these automatic negative thoughts and respond by saying, “Okay, but what’s the evidence for that? Is there any other way to think about that? Is there any evidence against it?” We’re negotiating for a more neutral, less negative thought to take the place of that—one that wouldn’t wreak as much havoc on mood.

For example, a frequent thought our patients report is “I hate winter.” If you’re in that hibernation mode on the couch under a blanket, after the sun sets, and you’re sitting there repetitively thinking to yourself, “I hate winter; this is awful,” the effect would be to feel worse, not better. The first step is to recognize: “Okay I’m having this thought—I hate winter—and it makes me feel worse when I have this thought. So what else can I say to myself?” It might be a fact that you don’t love winter, so a replacement thought could be as simple as “I prefer summer to winter.” It’s more of a mood-neutral thought. Making those adjustments helps patients recognize these patterns of negative thinking and interrupt them with neutral thoughts.

We’re on our fourth study now in this line of research, and our findings have been fairly consistent. They’ve demonstrated that light therapy and CBT both work very well at improving the acute symptoms of SAD across six weeks in the winter. When we followed people into future winters, we’ve also seen fewer relapses of full-blown depression and less-severe symptoms of depression overall following CBT relative to following light therapy. It’s a similar outcome to those found with nonseasonal depression.

The treatment manual is published by Oxford University Press, and it’s called Coping with the Seasons: A Cognitive Behavioral Approach to Seasonal Affective Disorder. Mental health providers are able to use the protocol if they are interested in it.

It often takes about fifteen years from the time you have published data showing that a treatment is effective until the community begins to consume that, and everyday practitioners start using it. It’s called the gap. The gap between research and practice is a problem in the field of psychology in terms of dissemination. I continue to research, publishing my findings, and hope that it will spread so that people can start using it.

Individuals can tell their provider they’ve heard of this CBT-SAD approach and ask whether that’s something they would be willing to work with you on. The treatment manual is designed for professionals, so I wouldn’t encourage someone who thinks they have SAD to buy it and try to use it on their own.

Resist the urge to self-diagnose and self-treat. Seek evaluation from a qualified person who can figure out once and for all if it’s SAD or if it might be something else, including a depression that’s not following a seasonal course. And know that there are treatment options out there that are effective, including light therapy, antidepressant medications, and cognitive behavioral therapy. So there are reasons to be optimistic that one of these interventions will be helpful in terms of improving your experience.

I would not suggest people go and buy a light box if they’re starting to feel depressed as the fall months begin. Even though I think of light therapy as a medical device, it’s important to remember that they are not FDA-regulated. Just because you can get access to it doesn’t mean that you should. The dosing for light therapy that I previously mentioned is based on trial and error. There is no one-size-fits-all prescription for light therapy. There are side effects that include headaches, eye strain, and feeling wired or jazzed up. More-serious side effects could include a shift in your sleep cycle, triggering insomnia. You could experience difficulty falling asleep or waking up early, unable to fall back asleep. Rare but serious side effects include mania and hypomania, or dangerously elevated mood states that are associated with bipolar disorders. Someone could develop mania or hypomania without having a prior history of those. If light therapy is recommended, work with someone who can monitor your symptoms and find the accurate dosing.

As an introduction to different treatment options, I recommend Winter Blues: Everything You Need to Know to Beat Seasonal Affective Disorder. It was written by the definitive expert on SAD, Normal Rosenthal, and it has a lot of information on the different treatment options for SAD.

If you’re interested in trying cognitive behavioral therapy for SAD (CBT-SAD) and are looking for a therapist in a particular location, I recommend looking at the Association of Behavioral and Cognitive Therapies to find a therapist and/or the Academy of Cognitive Therapy to find a certified cognitive therapist.

If you know you have this pattern, prevention is easier than treatment. It’s a lot easier to ward off an episode of winter depression than to try to dig yourself out once you’re feeling the full brunt of it.

This involves being consistent with what has worked for you in the past. If that’s an antidepressant medication, make sure that you’re on it in advance of the symptoms. Some providers may recommend staying on it year-round in order to avoid going off and on it.

If it’s light therapy that has been effective for you, continue your light therapy the very first day you feel seasonally depressed. Clinical practice guidelines say that the day you have your first symptom is the day you should resume your routine of daily light therapy.