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Tuesday, 3 February 2015

Seasonal Affective Disorder (SAD)

What is it?
Seasonal Affective Disorder (SAD) has been described as “a recurrent disorder involving seasonal episodes of depression, usually in the winter months”. Occasionally though, the depression may be felt in the summer.

This is not a new problem. It has been written that even in 200 AD a link between sunlight and depression had been recognised, and it was recommended that "lethargics are to be laid in the light and exposed to the rays of the sun"!  

Most of us are affected to some extent by changes in season, for example, feeling brighter and more energetic on a sunny day. However, for people with SAD, these changes in mood as the seasons change are far more pronounced, and consequently have a significant impact on quality of life during these times. Indeed, some people with SAD report feeling unable to get out of bed in the morning when their mood is at its lowest ebb.

Who does it affect?
SAD is thought to affect approximately 2% of adults, and to affect women twice as commonly as men. SAD is more common in countries where there are significant changes to number of daylight hours, temperature and weather conditions between seasons.

Some or all of these may be experienced:

• Low mood, feelings of guilt
• Apathy
• Lethargy
• Poor concentration
• Anxiety, panic attacks
• Irritability
• Sleep problems – usually more sleep
• Overeating, often with cravings for chocolate and high-carbohydrate foods
• Alcohol or drug abuse
• Weight gain
• Possibly lowered immunity, with increased incidence of illness
• Relationship difficulties, inability to socialise

Symptoms usually begin in the autumn months as daylight reduces, and start to improve in the spring. December to February tends to be when symptoms are at their most severe.

SAD is rare in childhood. However, when children are affected, it may present as irritability and sluggishness.

What Causes SAD?
The exact cause(s) are unclear. Women in their reproductive years are most at risk, as is the case for all forms of depression, suggesting a hormonal link. Obviously, reduced daylight is another causal factor. It is thought that this relative lack of sunlight affects levels of the brain chemicals serotonin and melatonin.

Serotonin, also known as 5-hydroxytryptamine, is a monoamine vasoconstrictor, derived from the amino acid, tryptophan from protein. It is found in high concentrations in many body tissues, including the wall of the intestine, pineal body, in the blood, and the central nervous system. It is involved in mediating numerous functions, such as reducing stomach acid secretion and serving as a neurotransmitter (messenger in the nervous system).

People with SAD have been found to have reduced serotonin levels, especially in the winter. Given the number of widespread roles of serotonin in the body, it is easy to see how low levels would potentially result in many symptoms.

Melatonin is a hormone produced from serotonin in the pineal gland in the brain. Melatonin secretion is high at night (which makes us sleep) and low during the day (hence, we wake). It is involved in the regulation of sleep, mood, puberty and ovarian cycles. Indeed, the pineal gland plays a major role in establishing circadian rhythms ("body clock"). Bright light inhibits melatonin secretion, hence it is often recommended that people with insomnia should not use computers or be in other brightly lit situations immediately before bed.

People with SAD have raised melatonin levels. Studies have found that when people with SAD increase their exposure to light, their melatonin levels fall to within normal range, yet continue to experience the symptoms of SAD. This suggests that raised melatonin is not the only causal factor involved in developing SAD.

Disrupted circadian rhythm ("body clock")
The body normally regulates functions such as digestion, sleep and energy levels throughout each 24 hour period. However, reduced sunlight can disrupt this regulation, leading to SAD symptoms such as depression.

Other possible causes or triggers of SAD
Other triggers which have been suggested include:

  • trauma or a major stressful event
  • serious illness
  • medication
  • withdrawal from drugs or alcohol
  • relocation from a region nearer the equator 

General self-help strategies:
  • Exercise helps all forms of depression. Walking is an excellent, safe, exercise for most people.
  • Time outdoors, especially around midday (or sitting by a bright window) increases daylight exposure, so helping symptoms. Limit use of sunglasses when experiencing SAD.
  • Try to be optimistic, reminding yourself that the depression will lift.
  • Tell others you have SAD, so they are likely to be more understanding.
  • Avoid stress as much as possible.
  • Improve diet. Attempt to avoid eating excess carbohydrates. 
NB. Spending time in a sunny location (eg. a holiday) whilst affected by SAD may reduce symptoms temporarily, but then lead to an exacerbation on returning home, since SAD is usually a reaction to changes in season. 

Light Therapy
Light boxes are growing in popularity as a therapy to reduce symptoms of SAD (see links below). They emit bright light, but without the harmful Ultra Violet Radiation (UVR). Light boxes are available in different strengths and sizes. They are generally more effective when used in the early morning, and for approximately half to two hours, but the most effective use varies between people, with the brightness of the day and with the box used. It is advisable to not use them before bed though, as this may cause insomnia (see melatonin above).

Dawn-stimulating alarm clocks, although less bright than light boxes, can be used to gradually increase light in the hour before waking. This can be especially useful if someone finds it difficult to wake up in the morning when affected by SAD.

Occasionally, light therapy may cause headaches or blurred vision.

....even though it is sometimes said that they are!

Talking therapies
Talking therapies can be a useful adjunct. Cognitive Behaviour Therapy (CBT), which aims to change mood by altering thought patterns, may help. Counselling and psychotherapy are worth considering.

NHS therapists (see your GP to be referred) often have long waiting lists. If considering consulting a therapist privately, it is important to look for one who is properly qualified and registered. The British Association for Counselling and Psychotherapy (BACP) has a list of such accredited practitioners in each area (see links below).

Antidepressant medications are often prescribed. These do not cure SAD, but may reduce symptoms. The antidepressant drugs usually given are SSRIs (Selective Serotonin Reuptake Inhibitors), for example, paroxetine (Seroxat), Fluoxetine (Prozac), Sertraline (Lustral).

St John's Wort (Hypericum perforatum)
Many people have reported finding St John's Wort beneficial.

NB. Herbalists use whole plant extracts of St John's Wort, rather than extracts which contain isolated constituents from the plant, as tends to be the case in over-the-counter preparations. This is because whole plant extracts are believed to be safer, having been used safely in this way for many generations. In contrast, the use of isolated constituents is relatively new, and has been associated with side-effects.

St John's Wort (Hypericum perforatum)

St John's Wort has many useful actions. However, its effect on improving mood is believed to be partly achieved by blocking the re-uptake of dopamine, serotonin, noradrenaline and Gamma AminoButyric Acid (GABA).

Although it was once considered that the active constituents in St John's Wort were hypericin and pseudohypericin, it is know known that hyperforin, chlorogenic acid, rutin and quercitin are also required - hence the benefit of herbalists using whole plant extracts which do not remove these other vital constituents! It is likely, as is the case for the majority of herbs, that St John's Wort exerts its action through the synergy of its constituents. It is often the case, for example, that many constituents are required for the main active constituents to be absorbed.  

*St John's Wort can be used in conjunction with light boxes, as the function of these boxes is to act via the eyes (not the skin) and they emit visible light, not UVR, as reported by the Skin Cancer Foundation (see above, and also the relevant link below). It is usually advised to use a light box with a UVR filter in order to ensure this is the case.

St John's Wort may not be suitable for everyone. If in doubt, check!
Other herbs which have been used to help mood:
A great many herbs have been used to help mood. A few are mentioned below. Herbalists rarely use herbs singly. Instead, a few herbs are combined, with the individual's case history in mind. A carefully balanced prescription of herbs will select those which work well together and are most suitable for that particular person.

Lemon Balm (Melissa officinalis)
Lemon balm has a long history of use as a herb to help banish "the blues". Indeed, the 17th Century herbalist, John Evelyn wrote "balm is sovereign for the brain, strengthening the memory, and powerfully chasing away melancholy". Lemon balm has numerous other applications, for example, it is also taken by people to help alleviate anxiety and/or digestive problems. Studies are emerging which appear to back up these traditional uses. Furthermore, there is mounting evidence for the use of lemon balm to address Alzheimer's disease.

Rosemary (Rosmarinus officinalis)
Many old herbal texts describe rosemary as a "thymoleptic", ie. to improve low mood. The old saying "rosemary is for remembrance" refers to the age-old use of rosemary for increasing blood flow to the brain, so potentially improving memory. Rosemary has numerous other uses, as is often the case with herbs. These uses are increasingly supported by modern research.

Lavender (Lavandula angustifolia)
Lavender is another plant with a long history of traditional use for easing low mood, anxiety, insomnia and for improving memory. It also has uses in the gastrointestinal tract. Its use as a medicine is not new, having been popular since the late Middle Ages. The herbalist John Parkinson (1640) described lavender as being of "good use for all griefs and pains of the head and brain". It probably goes without saying that this is a wonderfully aromatic plant, rich in volatile oils, which studies show have antioxidant and anti-inflammatory actions.

References, useful links and further reading
British Association for Counselling and Psychotherapy (BACP)
For a list of accredited practitioners in your area, for talking therapies.

Grieve, M. (1931). A Modern Herbal. Mineola: Dover Publications. P76-77

Living Life to the Full
Free online CBT information, supported by the Scottish NHS

For information on light boxes (as recommended by MIND)

MIND for mental health 
Understanding Seasonal Affective Disorder (2013) – Fact sheet/PDF [online]. Available from: NHS Choices [Accessed15th January, 2015]

Partonen, T. & Magnusson, A. (2001). Seasonal Affective Disorder: Practice and Research. Oxford University Press. 

Persaud, R. (2007). The Mind. A User's Guide. London: Bantam Press. P205-211

Rang, H.P., Dale, M.M., Ritter, J.M., Flower, R.J. (2007). Rang and Dale's Pharmacology, 6th Ed. Philadelphia: Churchill Livingstone. P189-197 

Rosenthal, N.E. (2005). Winter Blues: Everything You Need to Know to Beat Seasonal Affective Disorder. New York: Guilford Press.

Seasonal Affective Disorder Association (SADA) 
For information and support

Seasonal Affective Disorder shop 
Information line: 01704 500 505
For information on light boxes and SAD (as recommended by MIND)

Simon, C., Everitt, H. & Dorp, F. (2010). Oxford Handbook of General Practice, 3rd Ed. Oxford: Oxford University Press. P1001

Skin Cancer Foundation
For information on how tanning salons are NOT a treatment for SAD!
[Accessed15th January, 2015]

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