Seasonal Affective Disorder (SAD): How to Beat it Without a Fight

We all love nature. We appreciate its wide variety and sheer beauty. It reminds us of the simplicity of life, and gives us a sense of pleasure and freedom. At the same time, we understand the importance of nature, and our dependence on it for our wellbeing and even our very own existence. We are perfectly aware of its tremendous power and its profound impact on us. One of the numerous ways that nature demonstrates this power is through the quarterly seasonal changes that takes place every year.

Each season brings its own unique character and the specific set of experiences that come with it - some of which are considered positive, while some are negative, and others somewhere in-between. In fact, the seasonal effects on humans are so significant that it has been found to cause a certain type of mental health condition that occurs only during specific times of the year - a condition called Seasonal Affective Disorder (SAD).

Seasonal Affective Disorder (SAD)

Seasonal Affective Disorder (SAD) can be simply defined as:

A type of depression that follows a seasonal pattern.

In other words, it is a subtype of depression that is specifically triggered by the change of seasons, and occurs at the same time each year in individuals who have normal mental health throughout the remainder of the year. It is more common during the autumn or winter months - hence also the name 'winter depression' - and the symptoms usually subside by the start of spring. This is different from the 'winter blues' - a milder from of SAD - that causes temporary low mood during the colder months, but it does not have the same severity or impact of SAD which can result in a certain degree of disruption to daily life.

Another form of SAD exists called 'summer depression' which is a mood disorder that contrastingly takes place at the start of the summer and ends by autumn or winter, but this is a much less common version of SAD with an incidence rate of approximately 10% of total number of cases only.

Other names for Seasonal Affective Disorder (SAD) are:

• Seasonal mood disorder.
• Depressive disorder with seasonal pattern.
• Winter depression.
• Summer depression.
• Seasonal depression.

SAD: Incidence and Risk Factors

SAD affects around 0.5 to 3% of the general population, often affecting the young adult population belonging to the age group between 20 to 30, and is more common in females compared to males. Other factors that can increase the risk of developing SAD are:

• Living far North or far South of the equator - which is linked to larger seasonal variations and reduced sunlight in those regions.

• A pre-existing mental health disorder such as clinical depression (approx. 10% of cases) or bipolar disorder (approx. 25% of cases).

• Family history of SAD, other forms of depression, or other mental health disorders.

SAD: Signs and Symptoms

Symptoms of SAD are similar to those experienced in clinical depression but these specifically follow a seasonal pattern, such as:

• Persistent feelings of sadness.
• General lack of interest or enjoyment in tasks or activities that were previously enjoyable.
• Decreased energy and fatigue.
• Low self-esteem.
• Feelings of hopelessness, guilt and/ or worthlessness.
• Weight changes and issues with appetite.
• Sleep disorders.
• Decreased libido.
• Difficulty concentrating.
• Feelings of irritability or agitation.
• Social withdrawal.
• Suicidal ideation.

In addition to the above, there are specific symptoms that are associated with the time period during which the disorder appears:

SAD (winter pattern)

• Oversleeping (hypersomnia).
• Overeating, with particular craving for consumption of carbohydrates.
• Weight gain.

SAD (summer pattern)

• Difficulty sleeping (insomnia).
• Poor appetite.
• Weight loss.
• Restlessness and anxiety.
• Episodes of violent behavior.

For people suffering from SAD, symptoms usually last for 40% of the year, and are not present in consecutive winters in around 30% to 50% of those affected. Contrastingly, symptoms of SAD can persist even after winter and do not subside by the summer in 40% of individuals leading to a change in diagnosis to either major depressive disorder or bipolar disorder.

SAD: Causes

SAD is a complex condition and its exact cause is not yet known. However, research has found a direct link with reduced exposure to natural daylight during the shorter days of autumn and winter, especially in individuals who are at particular risk of developing mood disorders i.e. those with a genetic predisposition that makes them more sensitive to seasonal changes.

There are a number of plausible theories for the possible triggers of SAD including the following:

Disruption to circadian rhythm

Affected individuals have been often found to have a disrupted daily rhythm i.e. sleep-wake cycle, during the the change in night-day pattern of the shorter days, making it difficult for them to adjust adequately and therefore resulting in sleep and mood disturbances, and overall altered behaviour throughout the day and winter period.

Hormonal imbalance

Sunlight has a major impact on the normal functioning of the hypothalamus - a small structure found deep inside the brain that helps regulate the normal sleep and aousal process.

Lack of adequate sunlight causes abnormal regulation of certain key hormones by the hypothalamus - melatonin, serotonin, and dopamine - which all play an important role in regulating mood, appetite and sleep.

Vitamin D deficiency

It is a well-known fact that reduced daylight during the winter months often results in vitamin D deficiency because natural sunlight plays a central role in its production, and since vitamin D helps in the regulation of serotonin, this causes a disruption in the level of this essential hormone in the brain which subsequently results in disruption to mood and sleep.

Changes to weather and temperature

Some people are generally more sensitive to changes in their external environment such as the drop in temperatures and the increase in clouds in the skies. This makes it more tricky for them to adjust their mood and behaviour on a daily basis therefore increasing their likelihood of developing significant mood disorders during this specific time period. For this reason, SAD tends to be more common in certain regions where there the weather is often less stable and there is bigger variation between seasons e.g. UK.

SAD: Diagnosis

Diagnosis of SAD is based on meeting specific criteria as follows:

1. Exhibiting symptoms of clinical depression only at particular times of the year.
2. Having depressive episodes occurring during specific seasons for a duration of at least two consecutive years.
3. Having seasonal depressive episodes that outnumber other depressive episodes occuring at different times throughout life.

If there is any suspicion of SAD, the individual must seek help from their healthcare provider to confirm diagnosis, in order to then be capable to take the following steps to address the problems.

SAD: Treatment?

A wide range of treatments are available for the effective treatment of SAD, which are often tailored to the lifestyle and needs of each individual. The main treatments options consist of the following:

• Increasing exposure to natural light - This constitutes spending more time outdoors and/ or allowing more natural daylight into the home or office.

• Exercise - In addition to being essential for maintaining optimal physical health, doing regular physical exercise, especially in the outdoors, has astonishing consequences on the individual's mental health and overall wellbeing even when the weather is not so great.

• Stress management - Following effective and healthy techniques for managing stress e.g. meditation, yoga, or socialising with others, have been proven to improve mood control and decrease levels of stress and anxiety.

• Light therapy or phototherapy - This is the mainstay of treatment for SAD, and involves mimicking natural daylight by using a 'lightbox' that emits very bright artificial light. For this type of therapy to be effective, exposure must take place on a daily basis for a period of between 30 to 45 minutes. Treatment usually begins early in the morning starting in autumn until the spring which is the period when the days are relatively the shortest - meaning less exposure to natural light. This is considered a safe treatment for SAD because it filters out harmful UV rays, but may not be safe for all especially for individuals with certain eye or skin conditions or those on specific medications that increase their sensitivity to bright light, in which case alternative treatments should be considered.

• Cognitive behavioural therapy (CBT) - This is a form of 'talking therapy' and is a very effective form of treatment for a variety of mental health disorders including depression and SAD. It is a goal-based therapy that focuses on the relation between one's emotions, thoughts and actions. The main aim of this type of therapy is to better manage the individual's thought processes and behaviour patterns by applying effective coping mechanisms and identifying positive alternatives.

• Drug therapy - This involves prescribing anti-depressants, and is the treatment of choice for persistent or severe cases. Selective serotonin reuptake inhibitors (SSRIs) are usually the first-line treatment since they have relatively fewer side effects than other classes of anti-depressants. The drugs generally work by increasing levels of serotonin in the brain by blocking their reabsorption by the nerve cell. Research has shown that a rise in serotonin levels has an overall positive effect on symptoms and improves response to other mode of treatment e.g. CBT.

• Combination therapy (e.g. SSRIs and CBT or SSRIs and light box) - Research has shown that combining two types of therapies together is more effective than giving either treatment on its own and is more likely to improve outcomes in the long term, especially because the benefits are synergistic and mode of action is independent to each other.

• Vitamin D supplements - A clear link has been made between Vitamin D - or the 'sunshine vitamin' - and mental health. Since sunlight is essential for the vitamin's production, it makes perfect sense to top up levels of this vitamin during the darker months by taking Vitamin D supplements, in addition to other vitamins such as Vitamin B6, and B12 as well as omega fatty-acids which are all known to have an impact on mood and energy levels.

• Healthy diet - The relation between nutrition and mental health is very important for our overall health and wellbeing. It is best advised to consume nutritious food with emphasis on quality and variety, while limiting consumption of processed food, junk food, foods high in carbohydrates, or high-sugar/ high-salt type of foods in order to maintain a healthy body and mind.

Summary

The changing seasons and weather patterns are essential parts of life. We must accept this fact and learn how to even make the best out of it. However, in order to do that effectively, we must first embrace this change, and integrate it into the very foundation of our lives. It is necessary to be able to understand our own emotions and behaviours, and how our external environment can affect us even if we have no control over it. By arming ourselves with all this crucial knowledge, it becomes easier for us to be proactive in managing our own feelings and actions, and makes it more likely to have a successful transition between seasons. Because, ultimately, our aim is to achieve a 'HAPPY' state of wellbeing instead of becoming 'SAD' even in the darkest and coldest of times.

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References:

MedlinePlus (2019) Seasonal Affective Disorder. Available at: https://medlineplus.gov/genetics/condition/seasonal-affective-disorder/ [Accessed 16/03/23]

Cleveland Clinic (2022) Seasonal Affective Disorder (SAD). Available at: https://my.clevelandclinic.org/health/diseases/9293-seasonal-depression [Accessed 16/03/23]

National Institute of Mental Health (2022). Seasonal Affective Disorder. Available at: https://www.nimh.nih.gov/health/publications/seasonal-affective-disorder [Accessed 17/03/23]

NHS Inform (2023). Seasonal Affective Disorder. Available at: https://www.nhsinform.scot/illnesses-and-conditions/mental-health/seasonal-affective-disorder-sad [Accessed 17/03/23]

Chapman, S. (2019). Preventing seasonal affective disorder (SAD): light on evidence. Available at: https://www.evidentlycochrane.net/preventing-seasonal-affective-disorder-sad/ [Accessed 18/03/23]

Restworks (2022). Light Box Therapy for Seasonal Affective Disorder (SAD). Available at: https://rest.works/en/article/light-box-therapy-for-seasonal-affective-disorder/ [Accessed 18/03/23]

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