seasonal affective disorder
It’s this time of the year again, autumn. The time for great wines and game and truffle and ….. Also time for some of us to sit behind your lamps every morning for half an hour for two weeks on stretch against seasonal affective disorder.
Depressive disorder is not the only disease influenced by seasonality. In a large retrospective study in Bejing the presentation of Acute Coronary Syndrome which usually presents in the late stages of coronary heart disease also has a significantly seasonal and monthly rhythm.
The highest seasonal incidence occurred in winter and decreased as the season changed from winter to autumn, the monthly cases reached it’s high in March and it’s lowest in September as can be seen in the graphs above.
Beijing is characterized by warm temperate subhumid continental monsoon climatic zone with 4 distinct seasons. Seasons are defined as spring (March to May), summer (June to August), autumn (from September to November), and winter (from December to February).
They also looked at other weather conditions. Acute coronary syndrome had an inverse relationship with temperature and barometric pressure. Any other seasonality disorders?
Li, Y., Du, T., Lewin, M., Wang, H., Ji, X., Zhang, Y., Xu, T., Xu, L., & Wu, J. (2010). The seasonality of acute coronary syndrome and its relations with climatic parameters The American Journal of Emergency Medicine DOI: 10.1016/j.ajem.2010.02.027
- patients with depression often complain of difficulty getting to sleep, frequent awakenings during the night, early morning awakening, or nonrestorative sleep
- patients with mood disorders exhibit higher rates of sleep disturbance than the general population, and sleep disturbance can continue even during periods of remission
- patients with insomnia are up to 10 times more likely to have depression than normal sleepers
- individuals with persistent insomnia have a significantly higher risk of developing new-onset depression than those who have no sleep complaints
- 14% of patients with persistent insomnia had concurrent depression whereas depression occurred in less than 1% of patients who had no sleep complaints
- patients with persistent insomnia had a substantially higher risk of developing a new major depression compared with those whose insomnia resolved
These observations don’t explain the relationship between insomnia and depression. Insomnia can precede or co-occur with depression. Moreover, not only insomnia but also excessive sleep and fatigue has been associated with depression, more exactly with seasonal affective disorder and atypical depression. The’re a number of biological mechanisms hypothesized to explain the relationship between sleep disorders and depression.
- deficits in monoaminergic neurotransmission
- abnormalities in circadian genes
- overactivity of the hypothalamic–pituitary–adrenal (HPA) axis
- impaired functioning of plasticity-related gene cascades
Never heard of this last hypotheses before. Is an interesting one especially in relation to sleep deprivation as treatment of depression.
Neural plasticity is closely linked to learning, sleep and cortisol regulation for example, genes related to plasticity increase expression during waking, whereas genes related to synaptic downscaling are expressed during sleep, particularly SWS. It is feasible that sleep is required for the downscaling of synapses on a daily basis and that alterations in sleep and/or mood disorders could affect this process. Conversely, sleep deprivation may increase plasticity-related gene expression, strengthening synapses in brain regions involved in mood regulation, and it is this hypothesis that helps to explain some of the acute antidepressant effects of sleep deprivation therapies
Benzodiazepines are not a good treatment for insomnia, not in depression nor without depression. Benzodiazepines have disadvantages: adverse events, withdrawal potential, lack of longterm safety, and potential for rebound insomnia. Antidepressants are a better choice for insomnia and insomnia with depression. Tricyclic antidepressants all improve restorative sleep and are very efficacious in treating depression.
BENCA, R., & PETERSON, M. (2008). Insomnia and depression Sleep Medicine, 9 DOI: 10.1016/S1389-9457(08)70010-8
Holshoe, J. (2009). Antidepressants and Sleep: A Review Perspectives in Psychiatric Care, 45 (3), 191-197 DOI: 10.1111/j.1744-6163.2009.00221.x
Seasonal Affective Disorder (SAD) or Winter Depression can be succesfully treated with bright light therapy. Across studies, 53% of cases of SAD remit with bright light therapy. This involves sitting in front of full-spectrum lights that mimic sunlight on a regular basis — typically for about 30 minutes to 60 minutes each morning. Sometimes one or two weeks is sufficient but some patients will need this for the whole season. This hampers compliance with this therapy, only 41% of patients continued regular light therapy, 59% discontinued light therapy due to ineffectiviness and inconvenience. More important is the prevention of the recurrence of this kind of depressive episodes over subsequent winter seasons.
Cognitive behavioral Therapy could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy
This conclusion was based on a 1 year follow-up study of two pilot studies. The first was an uncontrolled feasability study comparing a novel group CBT, light therapy and the combination of both. The second was the first controlled study comparing CBT, light therapy and the combination of both in 61 patients with SAD compared to a control group of waiting list patients.
The researchers pooled all available data from the naturalistic follow up during the subsequent winter season of participants who had not dropped out of the study.
Both CBT and CBT with light therapy did significantly better at follow up compared to light therapy alone. CBT treated participants &% had another depressive episode in the subsequent winter season, fo CBT and light therapy 5,5%, and for light therapy alone 37%.
Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy
Limitations of this study
It was a naturalistic follow up study, the treatment duing this follow up period varied very much. The participants in the waiting list group from the second trial were not assessed.
A randomized controlled trial with follow up is still needed to confirm these promising results.
Rohan, K., Roecklein, K., Lacy, T., & Vacek, P. (2009). Winter Depression Recurrence One Year After Cognitive-Behavioral Therapy, Light Therapy, or Combination Treatment Behavior Therapy, 40 (3), 225-238 DOI: 10.1016/j.beth.2008.06.004
Light can have amazing effects and contrasts of light and dark. They can create beautiful effects or phenomena. This picture above is from a blog with 20 Most Incredible Light Phenomenas for your viewing pleasure. But light can also be used in depression.
Bright light therapy is an excellent candidate for inclusion into the therapeutic inventory available for the treatment of nonseasonal depression today, as adjuvant therapy to antidepressant medication. This was the result of a recent systematic review. To me light therapy for nonseasonal depression was new, which inspired the recent post on this blog about this topic.
Light therapy is mostly known for it’s primary use in seasonal affective disorder.In this post it is explained what a seasonal affective disorder is according to DSM IV criteria and it also has links to 8 articles on seasonal affective disorder.
Chronotherapeutics are controlled exposures to environmental stimuli that act on biological rythms in order to achieve therapeutic effects in psychiatric conditions.I was especialy interested in the implementation on psychiatric wards. Psychiatrists are usually not aware of the influence of simple measures such as light and exercise on mood and mood disorders. Six years ago we implemented running therapy on our unit for depressed inpatients. It is still a valuable form of therapy to our patients. We should consider using light as a therapeutic. Follow this link about Chronotherapeutics and it’s use in psychiatry for more information.