By: Eyuel Terefe, MD WWH psychiatrist 

For it is the season, the season for giving, the season for thanks and holidays. Yet, it is also the time of winter, which robs the light of our days like the grinch! Unfortunately, this seasonal variability and reduction of light exposure translates to a psychiatric condition that heightens during the transition from fall to winter months, aptly called a Seasonal Affective Disorder, appropriately abbreviated as SAD, and also known as major depressive disorder with a seasonal pattern. This remarkable phenomenon of mood alterations secondary to seasonal change and diminishing light exposure is unique to SAD. It causes a form of temporal depression in which there is a recurrent pattern of depression symptoms during specific seasons of the year and resolves once the particular seasons have ended – generally the summer when our days and mood brighten up literally and figuratively. The fascinating mechanism and chronology of symptoms recurrence and exacerbation correlate to diminished sun exposure of our skin and eyes. Understandably, this is most prominent during winter when we actively cover up and spend a significant amount of our time indoors to keep cozy from the frigid storms of Wisconsin.

Thankfully, there is a treatment for SAD, which is quite convenient – called bright light therapy, which works by replenishing the missing sun exposure with a powerful light box exposure daily in the morning. Exposure to artificially generated light measured in potencies with units of Lux: generally, 10,000 Lux for 30 minutes in the morning, to be exact or much dimmer at 2,500 Lux over 2 hours in the morning. This treatment has the benefit of signaling our brain thru the optic nerve in our eyes which processes light and vision and enhances the production of serotonin neurotransmission (a neurotransmitter that regulates mood and is critical in treatment with antidepressants) for increased mood regularity and balance. This relationship has been a well-studied phenomenon of disease and treatment and was interestingly discovered with the onset of depression symptomology in polar explorers, which ultimately resolved with bright light treatment. There is a substantial correlation as diminishing sunlight correlates to decreased serotonin activity in the brain and is more prominent in patients with mood disorders. Additionally, this same light processing pathway modulated by our optic nerve assists us with circadian rhythm regulation and energy; thus, light therapy has the added benefit of waking us up in the morning with a jolt, enhancing our focus and concentration ability, and improving our circadian rhythm regularity to provide structure for our sleep difficulties at night by regulating melatonin production.

So, I am sure you are asking yourself if you might have SAD; well, it is a pretty common and underdiagnosed condition; it is very prominent in wintery wonderlands like Wisconsin.

Here are some common questions to ask yourself and to discuss with your doctor if you are worried about having seasonal depression.

Do you have recurring patterns of low mood and energy that are distressing or impairing, mainly occurring or worse during the fall and winter months?

Do these symptoms resolve in the spring and summertime or when you travel to another location/state/country?

Other symptoms that you might experience include: feeling irritable, frequently crying, being tired and lethargic, having difficulty concentrating, sleeping more than usual, lacking energy, decreased activity levels, withdrawing from social situations, craving carbohydrates, and sugars, and tending to gain weight due to overeating addition and less frequent symptoms poor appetite with associated weight loss, insomnia, agitation, restlessness, anxiety, and even episodes of violent behavior.

If you or a family member screens positive for all the questions above, please consider seeking an evaluation with a mental health specialist, and at least consider utilizing a sunlamp in the morning. At Western Wisconsin Health, we have taken the initiative to equip light boxes in our new and convenient pharmacy at the Baldwin main campus. Additionally, these light boxes can be obtained at online retailers (e.g., Amazon, with recommended manufacturer Circadian Optics costing about $20 and will last for years). These light boxes are thoughtful gifts and make unique stocking stuffers; thankfully, they have been modernized to be more sensible in their size and with enhanced Ultraviolet (UV) filters or UV free to protect the eyes from damaging rays. Be warned not directly to look at the light and to place it 2-3 feet away in the periphery vision and to only utilize them immediately upon awakening in the morning. Thirty-minute sessions are a typical starting duration, which can be adjusted upward or downward depending on response up to one hour per day; additionally, the light boxes’ strength may be adjusted to minimize eye strain. The response to treatment is evident within days to weeks, and the treatment should begin as early as possible in the fall and winter months. It should be continued until summertime, depending on the individual’s tolerability and response.

Understandably bright light therapy should be utilized in the morning best to optimize alertness for the rest of the day. It should be absolutely avoided in the afternoon and evening, as the light from 30 minutes of exposure is potent and possibly equivalent to 5-6 hours of natural sunlight. Lastly, bright light therapy should be rarely and minimally utilized or even avoided in anyone with a Bipolar diagnosis, as improving serotonin production could activate hypomanic and manic episodes in patients who are sensitive to neurotransmitter fluctuations – in fact, it is postulated that bipolar patients are more likely to be hospitalized for manic episodes during the summer due to such mechanism to excess natural sunlight exposure. Especially patients with macular degeneration should use bright light treatment only with the review or guidance of an ophthalmologist. Commonly seen adverse events associated with bright light therapy include eye irritation, headache, and nausea, usually resolved by increasing the distance of the eyes from the light, placing the lightbox overhead, or reducing the daily duration and dividing it into multiple small sessions of light therapy. There are promising newer forms of low-level infrared light therapy with Red light and Blue light treatments that offer even more unique and numerous various benefits, including enhancing immunity, improving acne, enhancing wound healing, improving cancer-related fatigue, reducing hair loss, reversing cognitive decline, boosting testosterone production in men, and enhancing the efficacy of antidepressants for treating even nonseasonal depression and an excellent option for adjunctive treatment for depression during pregnancy.

As in Game of Thrones and life, “Winter is coming” – however, SAD is a genuine medical condition of darkness and should not be taken “lightly”! There is a vast grade of the spectrum of seasonal affective disorder that can translate from a mild form called winter blues to very severe depression, which might warrant treatment with antidepressants such as Wellbutrin XL (Bupropion) or alternatives. SAD varies in presentation, frequency, and severity; the depressive episodes commonly begin in September to November, persist for months, and generally do not resolve until the following spring. Additionally, these episodes of depression can exacerbate other psychiatric symptomatology and significant distress and impair one’s day-to-day functioning; therefore, it is essential to ensure adequate treatment, monitoring, and assessment with therapy and psychiatry care for refractory symptoms that fail to improve with interventions of sun exposure. Treatment approaches typically include combinations of antidepressant medication, light therapy, Vitamin D, and counseling. Despite the unfriendliness of winter hardships, please ensure to take appropriate care, be socially engaged, be physically active, eat healthily, and take the necessary step to prevent SAD with bright light therapy.

If you are interested in improving your overall mental health and well-being, please call 715-684-1111 and schedule an appointment with a Western Wisconsin Health Behavioral Health professional. Western Wisconsin Health Building a Healthier Tomorrow, Together.

References: 

Bais B, Kamperman AM, Bijma HH, et al. Effects of bright light therapy for depression during pregnancy: a randomised, double-blind controlled trial. BMJ Open. 2020;10(10):e038030. Published 2020 Oct 28. doi:10.1136/bmjopen-2020-038030

Huberman, Andrew, host. “Using Light (Sunlight, Blue Light & Red Light) to Optimize Health. Huberman lab. Episode 68. April 18, 2022. https://hubermanlab.com/using-light-sunlight-blue-light-and-red-light-to-optimize-health/https://hubermanlab.com/using-light-sunlight-blue-light-and-red-light-to-optimize-health/

Lam RW, Levitt AJ, Levitan RD, et al. Efficacy of Bright Light Treatment, Fluoxetine, and the Combination in Patients With Nonseasonal Major Depressive Disorder: A Randomized Clinical Trial [published correction appears in JAMA Psychiatry. 2016 Jan;73(1):90]. JAMA Psychiatry. 2016;73(1):56-63.

Lam RW., Levitt AJ. Canadian Consensus Guidelines for the Treatment of SAD. A Summary of the Report of the Canadian Consensus Group on SAD. Vancouver, Canada: Clinical & Academic Publishing; 1999

Melrose S. Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. Depress Res Treat. 2015;2015:178564. doi:10.1155/2015/178564

Sit D, Wisner KL, Hanusa BH, Stull S, Terman M. Light therapy for bipolar disorder: a case series in women. Bipolar Disord. 2007;9(8):918-927. doi:10.1111/j.1399-5618.2007.00451.x