Separating Your Rhythms from the Blues: Normal Moods and Seasonal Depression. Sadness or Depression?

Transcription

1 Separating Your Rhythms from the Blues: Normal Moods and Seasonal Depression Sadness or Depression? 1

2 About 10% of the US population experience some form of Seasonal Affective Disorder (SAD) but only one or two percent of people experience symptoms severe enough to warrant medical care U.S. Department of Health and Human Services regards the Winter Blues as a general term, not a medical diagnosis, fairly common and more mild than serious. Winter Blues are known to usually clear up on their own Winter Blues are often linked to specific things, such as stressful holidays, reminders of absent loved ones or even slight symptoms of SAD that do not fully develop (News in Health). 2

3 People living at higher latitudes have shorter days in the winter and report more seasonal depression and more winter blues SAD Winter Blues 7.2% 20.2 % 6.1% 17.1% 5.0% 13.9% 3.9% 10.6% 2.8% 7.5% 3

4 Appear similar, but not major depression Avoid the Where s Waldo Diagnostic Method

5 Separating Your Rhythms from the Blues: Normal Moods and Seasonal Depression 5

6 Making sense of complexity Mood 101

7 Basic Questions /Vocabulary What is Mood? What is Normal Mood? What is Abnormal Mood? What is a Mood Disorder? How are Mood Disorders Diagnosed?

8 What is Mood? Affect vs Mood Objective feeling state Experience observed Variable overs seconds Like the Weather Subjective feeling state Experience reported Long Lasting Like the Climate

9 Normal Mood is Reactive to events with Amplitude Duration Direction appropriate to the meaning of the event for that individual

10 Understanding Abnormal Mood states: Depression: Diminished ability to respond positively to pleasurable events Mania: Diminished ability to respond appropriately to negative events

11 What is Depression?

12 Diagnosing Clinical Depression Requires 5 symptoms present to a significant degree nearly every day during a two week period Abnormal Mood state Depressed Mood Diminished Interest in Pleasurable Activities Plus Constellation of associated symptoms Slowed Speech or Movement Agitation Distractibility Decreased Concentration Low Self Esteem Excessive Guilt Appetite Increase or Decrease Sleep disturbance Increase or Decrease Decreased Energy Fatigue Suicidal Ideation

13 Diagnosing Clinical Major Depression MDE Requirement 5 DSM 5 Criteria Present to a significant degree nearly every day during a two week period Abnormal mood Depressed Mood state 1 Decreased interest/ diminished pleasure + + Associated Symptoms Sleep Disturbance Low Self Esteem/Guilty Decrease energy/fatigue Concentration difficulty Appetite Disturbance Psychomotor agitation/retardation Suicidal ideation/morbid thinking

14 Seasonal Affective Disorder specifies a pattern in DSM 5 Episodes meet full criteria for major depression and Coincide with specific seasons (appear in winter or summer months) for at least 2 years. Seasonal depressions must be much more frequent than any non-seasonal depressions. Winter Most Common Symptom Pattern of SAD Low energy Hypersomnia Overeating Weight gain Craving for carbohydrates Social withdrawal (feel like hibernating ) Summer Poor appetite with associated weight loss Insomnia Agitation Restlessness Anxiety Episodes of violent behavior

15 Putative Causes of Mood Disorders Genes Environment Stress Social defeat Neurotransmitters Receptors Transporters 2nd messengers Oxidative stress Cytokines Nutrition Mitochondrial dysfunction Circadian disruption Decreased neuropil HPA axis dysfunction Disconnection syndrome Cognition Temperament Nonadherence CZ SERO, March

16 Understanding Circadian Rhythms

17 Light is a potent zeitgeber (time giver) Zeitgebers: Tell the brain s clock (suprachiasmatic nucleus) what time it is

18 Entrained: Snychronized Rhythm (same cycle length )

19 Fall sleep Rhythms with common cycle length = Synchronized Wake-up Day 1 Day 2 Day 3 Free Running No Zeitgeber 25 hr cycle Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Entrained by Zeitgeber to 24 hr cycle

20 Fall sleep Rhythms with different cycle length drift = Desynchronized Wake-up Day 1 Day 2 Day 3 Un-entrained Free Running Desynchronized e.g. 25 hr and 27 hr cycles Day 4 Day 1 Day 2 Day 3 Day 4 Un-entrained Desynchronized e.g. 24 hr and 30 hr cycles Day 5 Day 6 Day 7

21 Entrained: Snychronized Rhythm (same cycle length )

22 Entrained Rhythms Your Body s Many Separate Organs Function like an Orchestra Synchrony maintained by Following the same biological clock 22

23 Entrained Rhythms

24 Getting through the season

25 Self-management strategies to help stabilize circadian rhythms Re- enforce your Zeitgebers Good sleep hygiene Intentionally couple activity with your sleep wake cycle Manage light exposure Honor social routines Common sense consumption Measure what you want to manage Sleep Weight Activity Mood

26 Put more into your care get more out Transform Your Engagement into Guidance Give yourself the gift of Measure-based Guidance at no cost Create and Share Pre-assessment Reports

27 1. Visit: EngagedPractice.com 2. Enter access code: engage2 A service provided by Collaborative Care Initiative

28 Engaged Practice Work Flow: Formal Measures Tab* AT A GLANCE VIEW: REPORT MADRS items 04/22/2016 Score Reported Sadness 4 Observed Sadness 4 Inner Tension 6 Reduced Sleep 2 Reduced Appetite 3 Conc Difficulties 5 Lassitude 4 Inability to feel 5 Pessimistic Thoughts 4 SI/ Morbid Thoughts 2 MADRS total 39 DSM Graphic View YMRS items *This is an example of software that can aid in patient assessment. There are other similar software available. DSM, Diagnostic and Statistical Manual of Mental Disorders; MADRS, Montgomery-Asberg Depression Rating Scale; PHQ-9, The Patient Health Questionnaire; QLESQ, Quality of Life Enjoyment Questionnaire; YMRS, Young Mania Rating Scale. Score Elevated Mood 2 Energy 3 Sexual Interest 0 Decreased need for sleep 1 Irritability 0 Speech 0 Language/thought process 0 Thought content 4 Disruptive/ Aggressive 0 Appearance 1 Insight 2 YMRS total 13 DSM Sensitive/Specific Self Reported items Ability to enjoy pleasant things/usual activities Score Sleep Self confidence/ Self Esteem -1.5 Energy Ability to concentrate -2.0 Distractibility 2.0 Physical restlessness/ agitation Rate of movement or rate of speech Feel life isn t worth living or suicidal thoughts Appetite Talking -1.5 Racing Thoughts 0 Making plans or getting new projects started Behavior others regard as excessive, foolish or risky PHQ-9 total 19 Measure Summary Q-LES-Q items Score Physical Health 5 Mood 1 Work 1 Household Activities 2 Social Relationships 2 Family Relationships 4 Leisure Activities 2 Ability to Function 1 Sex drive and interest 1 Economic status 2 Living/Housing situation 2 Ability to get around physically Vision in terms of ability to do work or hobbies Overall sense of well being 2 Overall satisfaction and contentment 5 2 Medication 2 Q-LES-Q total 32.1% 2

29 *This is an example of software that can aid in patient assessment. There are other similar software available. Conc decision, concentration decision; Decr sleep, decreased sleep; Dep mood, depressed mood; DSM, Diagnostic and Statistical Manual of Mental Disorders; elev mood, elevated mood; FOI/RT, flight of ideas or racing thoughts; Guilt Dec Engaged Practice Work Flow: Formal Measures Tab*

30 30 Instant Training: Visual Screening for MDE* Review process: *Count the criteria with bars reaching DSM threshold: Most Sensitive: 5 Most Specific: 5 with both bars Other: 5 of one source

31 Measure what you want to manage Engaged Practice : Formal Measures* * This is an example of software that can aid in patient assessment. There are other similar software available. MADRS, Montgomery-Asberg Depression Rating Scale; QLESQ, Quality of Life Enjoyment Questionnaire; STEP-BD, Systematic Treatment Enhancement Program for Bipolar Disorder; Wk, week; YMRS, Young Mania

32 Strengthening your Zietgebers

33 Be cautious with new antidepressant treatments (Especially those without FDA Approval) Mechanism of Action A novel Mechanism of Action can be attractive

34 Light Boxes None have FDA Approval for treatment of depression Light Visors Dawn Simulators

35 Pragmatics of Bright Light Treatment Light Source -Light Source Intensity: > 5000 Lux (1 Lux = light from 1 candle at 1 meter) Spectrum: Full spectrum (white) preferable (not red or infrared, not incandescent) -Distance: 1 meter (should be able to put your palm on the center of source) -Position: Direct to eye (do not stare at source) -Timing: Consistent time each day (morning may be best) -Duration: minutes 35

36 TIMING MATTERS ONLY AT THE START INITIAL EXPOSURES: PHASE DEPENDENT SHIFT REPEATED EXPOSURES: NO FURTHER SHIFT ESTABLISH ZIETGEBER

37 Paleo Lighting 1. Get a lot of natural, bright light during the day. 2. Maximize darkness around bedtime and during sleep Avoid trolling through social media before bed Use your cell phone s night shift setting

38 Call Call Call Links to Resources Light Products The Sunbox Company Sunbox.com Northern light Technologies northernlighttechnologies.com Mood Measures Collaborative Care Initiative EngagedPractice.com (access code: engage2) Free DBSA Wellness Tracker Free DBSAlliance.org/site/PageServer?pagename=wellness_tracker Activity and Sleep Monitoring Apps Fitbit Nokia Healthmate Free

39 Conclusion Recognize normal variation Maintain your rhythms Measure what you want to manage If in doubt contact your doctor 39