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Bright Nights Community Forum Seasonal Affective Disorder University of Michigan Depression Center Ann Arbor Public Library Bright Nights Forums U-M Depression Center and Ann Arbor Public Library Presentation on topics of interest relevant to mental health in community Panel of experts from U-M Depression Center and Professionals in community Q/A format Improve community awareness of resources available. Bright Nights Forums Bipolar Disorder: March 29th Suicide: May 24th Seasonal Affective Disorder What is Seasonal Affective Disorder - SAD Hypotheses surrounding SAD Research relevant to SAD Treatment options 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? SAD = Seasonal Affective Disorder Affective Disorder that occurs predictably at a specific season - most frequently in the fall or winter months. “Affective Disorder” is used interchangeably with “Mood Disorder” and usually refers to depression. Understanding Affective Disorders Kraepelin proposed affect to consist of 3 components Volition Emotion Energy & Drive Happy / Sad Intellect 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 Volition – drives – energy levels Emotion – mood (happy vs sad) Depression - lowered Depression – sad – low – guilt Intellect – thinking Depression – decreased rate - negative SAD - clinical features Clinicians refer to “atypical depressive sx’s” Sleep: hypersomnia - too much sleep 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 Appetite Increase (hyperphagia) Carbohydrate craving Comfort eating / grazing Eating at non-meal times “Atypical” because most people with depression experience decrease in appetite. Sub-syndromal SAD “Winter Blues” - “Winter Doldrums” Defies a clear definition…. 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 Slowed down / Irritable Some symptoms of atypical depression Over-eating & Over-sleeping SAD - Research Epidemiology: SAD ~ 1-3% 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. Middle latitudes (such as Michigan !) Extreme northern latitudes show lower frequency SAD Research Circadian Rhythms Photoperiod hypothesis: The shorter winter photoperiod results in SAD. Northern latitudes, controverted findings Melatonin secretion longer during winter in SAD Artificial light treats SAD Phase-shift hypothesis: Phase delay of circadian rhythm relative to external clock; waking later into evening and arising later in morning. Light therapy in am causes phase advance - correcting phase delay. SAD - Genetics Individuals with SAD frequently have family history of Depression (2/3) or SAD (1/3). Are there genetic variants that predispose to depression and SAD? Class of genes - “circadian clock genes” have shown association with SAD. Are there genetic variants of these “clock genes” associated with SAD. Preliminary evidence suggests this but not always replicated in independent studies. No specific tests to diagnose SAD. Controversies in SAD Phase delay / advance studies of circadian rhythm require rigorous monitoring of body chemicals, sleep EEGs, temp, etc. Small numbers of individuals studied Conclusions often conflict Conflicting results of effects of light therapy on phase change. Phase advance not always associated with clinical improvement. SAD - treatment Light therapy 30 min per day Begin with AM light 10,000 Lux Specialty light box Medication…. Usually required for major depression with seasonal pattern (10 - 15% respond to light alone) “Sub-syndromal” SAD Light therapy alone often lifts the “winter-blues” Ok for individual to buy box on own accord, buy from established company. Follow instructions Consult physician if taking medication. 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 20 studies reviewed for efficacy of light therapy in SAD. Very strong effectsize for light therapy 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 Possibility of …. Sleep disturbances Irritability Headache Eye irritation Marginal increase (but not significant) compared to control group. SAD - Conclusions SAD - refers to a seasonal pattern occuring in individuals with major Depression Symptoms are often “atypical” Sub-syndromal SAD is common Increased appetite and over-sleeping Noticeable qualitative change in functioning Light therapy is useful in treatment of SAD Effects noticeable within 2 weeks Difficult to establish routine of using light therapy…. Panel Members John Greden, MD Randy Nesse, MD St Joseph’s Medical Center Julie Kuebler, RN, NursePractioner University of Michigan Tom Zelnik, MD University of Michigan University of Michigan Laura Nitzberg, LCSW University of Michigan