“It was sort of a given that people were grouchy in the winter…It becomes a medical thing when it has consequences in people’s lives, like not being able to get to work or their quality of life going down the drain.”

– Dr. Norman Rosenthal, MD, Psychiatrist and one of the contributors to the initial research into Seasonal Affective Disorder

*Trigger warning*

Please note that this episode will cover topics related to depression, suicide, and mental health struggles and may contain sensitive or triggering content. If you or someone you love has been impacted by suicide, you are not alone. Please use your discretion when reading and connect to supports as needed. For those in Canada, Crisis Services Canada offers a national suicide prevention hotline which can be reached at 1 833 456 4566 or by text at 45645.

INTRODUCTION

Many of us living in the Northern Hemisphere are all too familiar with the sight of leaves gradually changing from green to red, orange, brown, and eventually dropping. When we see this, some may feel saddened as summer fun and late, light evenings give way to autumnal darkness and frigid temperatures. The desire to hibernate in a warm bed rather than face a cold, dark morning can translate into feelings of low energy and difficulties in getting motivated to complete daily tasks. This lower mood experienced in colder months is sometimes referred to as ‘winter blues.’ For some, however, these feelings can be overwhelming, drastically impacting daily life and necessitating clinical evaluation for seasonal affective disorder (SAD).

Table of Contents

In this blog post, we’ll be looking into the following:

●    What is Seasonal Affective Disorder?

●      Why Seasonal Affective Disorder is Important to Public Health

●   Treatment and Prevention of Seasonal Affective Disorder and ‘Winter Blues’

What is Seasonal Affective Disorder?

Seasonal affective disorder (SAD) is a form of depression that correlates to the changing of the seasons. Most people with SAD experience a ‘winter pattern’ where symptoms begin in the autumn and continue through the winter, then resolve in the spring and summer. While less common, some people experience ‘summer pattern’ SAD  where symptoms begin in the spring and resolve in the autumn and winter months (Mayo Clinic, 2022).

Symptoms of SAD can include:

People who experience symptoms to the point where their daily life and activities are impacted should seek help from a qualified mental health professional. SAD can be difficult to diagnose as many of the symptoms are consistent with other forms of depression. SAD is indicated when symptoms occur during specific seasons for at least two consecutive years. However, people diagnosed with SAD do not necessarily experience symptoms every year (National Institute of Mental Health, n.d.).

Those at a higher risk for SAD include

·       women

·       young adults

·       people with an existing major depressive disorder or bipolar disorder

·       people with a family history of SAD

·   people who live further from the equator, particularly in North America and Europe (Mayo Clinic, 2022; National Institute of Mental Health, n.d.; Sandman et al., 2016)

Specific causes of SAD are not entirely understood. Current research suggests that imbalances of serotonin, a neurotransmitter responsible for regulating mood and/or melatonin, a hormone responsible for regulating sleep patterns, may play a role in disrupting normal circadian rhythms (Mayo Clinic, 2022; National Institute of Mental Health, n.d.).

Vitamin D deficiencies may aggravate these imbalances as it is thought to facilitate serotonin activity. In the winter, decreased sunlight limits skin vitamin D production, exacerbating potential deficiencies (National Institute of Mental Health, n.d.).

Why Seasonal Affective Disorder is Important to Public Health

SAD prevalence estimates vary across regions and sources suggest that between 1% and 10% of individuals living in northern latitudes will experience SAD in their lifetime (Cotterell, 2010; National Institutes of Health, 2013; Sandman et al., 2016). As a form of depression, SAD contributes to the global health loss caused by mental health concerns. In Canada, 10% of depression is estimated to be seasonal (Canadian Mental Health Association, 2022). If left untreated, SAD can lead to problems at work or school, social withdrawal, substance abuse, and further mental health problems such as eating disorders, anxiety, and ADHD. In extreme cases, SAD can lead to thoughts of suicide (American Psychiatric Association, 2021; Mayo Clinic, 2022; National Institute of Mental Health, n.d.).

Many more people, about 15% – 20% of the population, experience the less serious version of ‘winter blues’ (Canadian Mental Health Association, 2022; Melrose, 2015; Targum & Rosenthal, 2008). While often not requiring formal intervention, people experiencing the associated low mood and fatigue may be less productive while experiencing sleep disturbances and changes in eating patterns (Targum & Rosenthal, 2008).

The ongoing, unpredictable COVID-19 crisis may be exacerbating the situation. Since 2020, the prevalence of anxiety and depression has more than doubled in several regions across the globe (OECD, 2021). Pandemic related strains on existing health facilities combined with limited appointment availability has disrupted access to mental health services. Coping mechanisms for SAD and the ‘winter blues’ include seeking sunshine outside or adventuring on a sun-soaked holiday. Lockdowns and travel restrictions have thwarted these remedies while distancing orders have limited contact with important social supports.

The increase in stress experienced during the pandemic as well as decreased access to the outdoors can impact serotonin and Vitamin D levels, potentially increasing the risk of SAD. Further research into the compounding mental health effect of COVID on SAD and the ‘winter blues’ is needed to help find solutions for those suffering the double mental health burden.

Treatment and Prevention of Seasonal Affective Disorder and the ‘Winter Blues’

For those with milder seasonal symptoms, ensuring self-care techniques are maintained through the difficult seasons can help improve mood and ease symptoms. Making indoor environments brighter and sitting near open windows can help improve symptoms during the winter months. Maintaining a healthy diet, regular outdoor exercise (even when the weather is poor), and sticking to consistent sleep patterns have shown to help people with the ‘winter blues’ and can work alongside other treatments for people with SAD (Canadian Mental Health Association, 2022; Mayo Clinic, 2022).

People with more severe symptoms should seek help from a qualified mental health specialist. The first-line treatment for winter pattern SAD is often light therapy, also called phototherapy. This involves sitting in front of a bright light (10,000 lux) for about 30-45 minutes usually soon after waking up in the morning. About 60-80% of people with SAD find that light therapy improves symptoms. There are few side-effects associated with light therapy; however, people should consult their health care provider before initiating treatment to ensure they use an appropriate and effective light box (Canadian Mental Health Association, 2022; Mayo Clinic, 2022; National Institute of Mental Health, n.d.).

Cognitive behavioural therapy (CBT) is a form of talk therapy that assists people in identifying problematic thinking patterns and negative thoughts while developing coping mechanisms and healthy behaviours. CBT has shown to be effective for SAD on its own or in combination with other treatments (Mayo Clinic, 2022; National Institute of Mental Health, n.d.)

Medications may also be prescribed to help combat SAD symptoms. As SAD is a form of depression, antidepressant medications can be effective. Vitamin D supplementation may also be helpful for people with low Vitamin D levels (National Institute of Mental Health, n.d.).

There is no known prevention for developing SAD or the winter blues. However, people who know that they experience mood shifts seasonally can start interventions before symptoms develop to help fend off the severe effects of the changing season (Mayo Clinic, 2022; National Institute of Mental Health, n.d.).

Effective treatments are available for SAD and the ‘winter blues,’ but access is not always equitable. Light boxes can be expensive and are often not covered through health insurance schemes. Accessing quality mental health services may be difficult for some due to availability, stigma, or simply not recognising that symptoms may warrant a visit to a health professional.  

Population level interventions are not yet well researched, but there have been trials in some areas. Some Nordic countries have lightrooms or sunlamps available for public use or in workplaces (Rastad, Wetterberg, & Martin, 2017). In Umeå, Sweden, several bus stops now have anti-SAD lights, allowing commuters exposure to a few minutes of light therapy (Borges et al., 2017). Exploring these and other population-based interventions may help reduce the impact of ‘winter blues’ while complementing the therapy for those with SAD.

Key Takeaways

While the transition into winter fills some with thoughts of fun-filled days in the snow, for others the cold, dark months bring a loss of energy, troubles sleeping, and feelings of hopelessness.

·       SAD affects millions of people every year with women, young adults, and people living at northern latitudes particularly at risk.

·       SAD contributes to the global burden of disease as a form of depression, causing suffers to experience low mood, fatigue, social withdrawal, and at its most extreme, thoughts of suicide. Many people suffer from ‘winter blues,’ which while considered a less serious concern, may impact productivity and wellbeing.

·       The effect of the pandemic on SAD is not yet understood, but COVID-19 control measures may be impacting the coping mechanisms for those who experience SAD and ‘winter blues.’

·       Effective treatments for SAD and ‘winter blues’ are available and can help ameliorate distressing symptoms.·       Interventions that help reach the wider population may help improve SAD and winter blues symptoms for the general public.

Written by: Malissa Underwood, BSN, MPH