Transcript Bright Nights Community Forum

Bright Nights
Community Forum
Seasonal Affective Disorder
University of Michigan Depression
Center
Ann Arbor Public Library
Bright Nights Forums
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U-M Depression Center and Ann Arbor
Public Library
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Presentation on topics of interest relevant to
mental health in community
Panel of experts from U-M Depression Center
and Professionals in community
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Q/A format
Improve community awareness of resources
available.
Bright Nights Forums
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Bipolar Disorder: March 29th
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Suicide: May 24th
Seasonal Affective Disorder
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What is Seasonal Affective Disorder - SAD
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Hypotheses surrounding SAD
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Research relevant to SAD
Treatment options
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The formal “Diagnosed” syndrome
Sub-syndromal SAD
Physical Treatments
Medication
Panel Discussion
On the treatment of disorders of mood…….
Live in rooms full of light
Avoid heavy food
Be moderate in the drinking of wine
Take massage, baths, exercise, and gymnastics
Fight insomnia with gentle rocking or the sound of running
water
Change surroundings and take long journeys
Strictly avoid frightening ideas
Indulge in cheerful conversation and amusements
Listen to music.
Cornelius Celsus (first century AD)
What is SAD?
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SAD = Seasonal Affective Disorder
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Affective Disorder that occurs predictably at a
specific season - most frequently in the fall or
winter months.
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“Affective Disorder” is used interchangeably
with “Mood Disorder” and usually refers to
depression.
Understanding Affective
Disorders
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Kraepelin proposed
affect to consist of 3
components
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Volition
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Emotion
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Energy & Drive
Happy / Sad
Intellect
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Rate of thoughts
Content of thoughts
Affect - Affection
Volition – the drive to care
for our offspring
Emotion – the love for our
children
Intellect – the thoughts &
speech related to our
interactions with family and
loved ones
Normal Affect
- Moods and disposition fluctuate over time
Volition
Emotion
Intellect
Depression
Volition
Emotion
Intellect
10
Mania
5
Volition
Emotion
Intellect
0
Affect and Affective Disorders
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Volition – drives – energy levels
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Emotion – mood (happy vs sad)
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Depression - lowered
Depression – sad – low – guilt
Intellect – thinking
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Depression – decreased rate - negative
SAD - clinical features
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Clinicians refer to “atypical depressive sx’s”
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Sleep: hypersomnia - too much sleep
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Difficulty getting out of bed
Slow to “get going”
Fatigued throughout the day
“Atypical” because majority of depressed patients
experience difficulties sleeping (frequent awakenings
during the night or awakening more that 1 or 2 hours
earlier than custom).
SAD - “atypical” features
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Appetite Increase (hyperphagia)
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Carbohydrate craving
Comfort eating / grazing
Eating at non-meal times
“Atypical” because most people with
depression experience decrease in
appetite.
Sub-syndromal SAD
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“Winter Blues” - “Winter Doldrums”
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Defies a clear definition….
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Common: 10 - 25% of middle latitude population
Does not meet diagnostic criteria for Depression
Milder form of SAD with distinct discomfort and
qualitative change in functioning (decrease) and
activity level
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Slowed down / Irritable
Some symptoms of atypical depression
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Over-eating & Over-sleeping
SAD - Research
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Epidemiology:
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SAD ~ 1-3%
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Sub-syndromal SAD (Winter Doldrums) ~25%
Chronic Course - ~40% with seasonal pattern at 10
year follow-up; 40% became non-seasonal.
High association with eating, anxiety, and substance
abuse disorders.
Associated with higher latitudes.
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Middle latitudes (such as Michigan !)
Extreme northern latitudes show lower frequency
SAD Research
Circadian Rhythms
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Photoperiod hypothesis:
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The shorter winter photoperiod results in SAD.
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Northern latitudes, controverted findings
Melatonin secretion longer during winter in SAD
Artificial light treats SAD
Phase-shift hypothesis:
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Phase delay of circadian rhythm relative to external
clock; waking later into evening and arising later in
morning.
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Light therapy in am causes phase advance - correcting
phase delay.
SAD - Genetics
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Individuals with SAD frequently have family
history of Depression (2/3) or SAD (1/3).
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Are there genetic variants that predispose to
depression and SAD?
Class of genes - “circadian clock genes” have
shown association with SAD.
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Are there genetic variants of these “clock genes”
associated with SAD.
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Preliminary evidence suggests this but not always replicated
in independent studies.
No specific tests to diagnose SAD.
Controversies in SAD
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Phase delay / advance studies of circadian
rhythm require rigorous monitoring of body
chemicals, sleep EEGs, temp, etc.
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Small numbers of individuals studied
Conclusions often conflict
Conflicting results of effects of light
therapy on phase change.
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Phase advance not always associated with
clinical improvement.
SAD - treatment
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Light therapy
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30 min per day
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Begin with AM light
10,000 Lux
Specialty light box
Medication….
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Usually required for
major depression with
seasonal pattern
(10 - 15% respond to
light alone)
“Sub-syndromal” SAD
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Light therapy alone often
lifts the “winter-blues”
Ok for individual to buy
box on own accord, buy
from established
company.
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Follow instructions
Consult physician if taking
medication.
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Some medications cause
light sensitivity.
Let there be light….
• Any light box you buy should have been tested successfully in peer-reviewed
clinical trials.
• The box should provide 10,000 lux of illumination at a comfortable sitting
distance. Product specifications are often missing or unverified.
• Fluorescent lamps should have a smooth diffusing screen that filters out
ultraviolet (UV) rays. UV rays are harmful to the eyes and skin.
• The lamps should give off white light rather than colored light. "Full spectrum"
lamps and blue (or bluish) lamps provide no known therapeutic advantage.
• The light should be projected downward toward the eyes at an angle to
minimize aversive visual glare.
• Smaller is not better: When using a compact light box, even small head movements
will take the eyes out of the therapeutic range of the light.
Center for Environmental Therapeutics - www.cet.org
Review of studies 1975 - 2003
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20 studies reviewed
for efficacy of light
therapy in SAD.
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Very strong effectsize for light therapy
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SAD
Non SAD depression
Golden et al, Am J Psych. 2005
Activity level improves using 4 weeks of Bright Lights
Side Effects of Bright Light
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Possibility of ….
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Sleep disturbances
Irritability
Headache
Eye irritation
Marginal increase (but not significant)
compared to control group.
SAD - Conclusions
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SAD - refers to a seasonal pattern occuring in
individuals with major Depression
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Symptoms are often “atypical”
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Sub-syndromal SAD is common
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Increased appetite and over-sleeping
Noticeable qualitative change in functioning
Light therapy is useful in treatment of SAD
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Effects noticeable within 2 weeks
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Difficult to establish routine of using light therapy….
Panel Members
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John Greden, MD
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Randy Nesse, MD
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St Joseph’s Medical Center
Julie Kuebler, RN, NursePractioner
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University of Michigan
Tom Zelnik, MD
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University of Michigan
University of Michigan
Laura Nitzberg, LCSW
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University of Michigan