Overcoming Seasonal Affective Disorder Webcast December 19, 2011 Pamela Sheffield, M.D. Crystal Wong, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion your own doctor, that s how you ll get care that s most appropriate for you. Understanding Seasonal Affective Disorder (SAD) Do the dark winter months make you feel a bit down, maybe very down? More sluggish or sleepier than usual? If so, you could be experiencing SAD, or seasonal affective disorder. Coming up we're joined by experts from UW Medicine in Seattle as they explore this disorder and share the best available strategies to help combat it. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by UW Medicine. I'm Andrew Schorr. Well, as we produce this program it is a December morning. It's foggy, gray. It's going to get dark really early. I have lived in Seattle for 23 years, and this time of year is really tough for me. It is tough to wake up. It's tough to get through the day. I pray it won't be rainy, I pray it will be sunny, and I notice a big difference when it is sunny and when the daylight is out there, and I try to turn every light on in my house. Well, some people are affected much more than that. They can barely get out of bed, and it is just really tough, and that can be something called seasonal affective disorder or SAD. Well, we have two family doctors with us. We're going to learn about that and what can be done. So let's start with Dr. Pamela Sheffield. She is a family medicine physician. She's chief at the UW neighborhood clinic in Ravenna in Seattle. Dr. Sheffield, welcome. So if someone comes in what would be the things they would describe and you'd say in your mind, that could be SAD? So around this time of year a lot of people feel a little more lethargic and tired than usual. People who have SAD are feeling really heavy and exhausted all the time, so they'll often describe a very physical symptom of feeling heaviness in their arms and legs. And they're sleeping all the time. Our usual depressed patients have difficulty sleeping, but people who have seasonal affective disorder are sleeping a lot. They don't want to get out of bed. The other thing we notice with people who have seasonal disorders as opposed to usual depression is that they're hungry. They're eating all the time and sometimes craving 1
carbohydrates, the kind of food that we tend to have in abundance around this time of year, the cookies and the pies and the breads. Often these patients have gained weight. They're irritable. They're not having a good time at work. Everything is bothering them, and they feel blue. Show with depression, traditional depression, people might not eat much at all, right? So this is different in that way. Right. Right. So this is a subset of depression that often presents with a little bit different symptoms. So the usual patient with a major depression is having difficulty sleeping. They also feel tired but in a different way because they're not sleeping well, and they often have a decreased appetite. Also joining us is a colleague of yours, that's Dr. Crystal Wong, who is also a family medicine physician at the UW Medicine neighborhood clinic in Ravenna in Seattle. Dr. Wong, tell me about how you identify this as a seasonal condition. What are the questions you ask a patient, and for our listeners what they would be asking themselves to say could this be SAD? Well, the thing about SAD is it's a specific subtype of depression, and I know that there's been a lot of press and it's in the media. We have more awareness about depression, but what sets apart SAD is that it specifically happens at certain times of the year. More often it happens in the fall. It's associated with increasing darkness, you know, decrease of daylight, and here in the Pacific Northwest that happens somewhat suddenly around this time of year. There have been some case reports of this actually happening in the springtime, although that's fairly rare. So what patients should be looking out for are the symptoms that they would associate with depression but happening more often in the fall and winter. Treating Seasonal Affective Disorder (SAD) Dr. Sheffield, is this a treatable condition? Yeah, absolutely. It's treatable, and for people that have recurrent episodes of seasonal depression it's actually somewhat preventable by attacking the symptoms and taking measures early in the season to try to prevent it getting so severe. All right. So let's say I felt this way last year, and it's really tough this year. What would I start doing and when? Where do we start? 2
Well, I think you start all year round, you know, with taking good care of yourself, avoiding stress, exercising regularly, eating right. And so, you know, all year round you want to be taking good care of your body, and as the seasons start to change I think the big piece of that you'd want to do is add some light therapy. I think one thing that's really common is when summer is over and fall hits we actually get worse in our self-care. Everybody gets busy, kids go back to school, we exercise less, we don't eat as well, and we're busier and more stressed out. So those things just combined with the seasonal change make everything worse. So you have to be aware that even though fall is coming and you're busy that you need to take time to take care of yourself. And then add light. We're going to talk about that in detail. Dr. Wong, so some people, you know, are outdoors of course when there's more sun and they're more active, and then they just don't feel like exercising and getting out as much. Can exercise help with SAD if we just try to keep doing it, whether we go to the gym or take a walk in the winter months? Most definitely. Exercise is one of the first-line treatments we use for any sort of mood disorder, whether that's depression or anxiety. There's something that is good about exercise for your body and for your mood, and so a big part of treatment for depression, whether that's seasonal or just our typical types of depression, is staying active. And we understand that it can be difficult to motivate yourself to go out, especially when you're not feeling good, but in all of the medical literature and all of the guidelines for treating depression exercise is tantamount. Dr. Sheffield, you mentioned about light. So there's a guy I see at Starbucks in the winter months. He goes early in the morning, doesn't bother anybody, sets up at one of those tables and looks like a makeup mirror almost, and he does his work for a little while with a light on. So what's he doing? What kind of light, where can you find them, and how does it make a difference? So there are a lot of different commercial light boxes that are available, and there's something about the light actually hitting your eye that probably affects your brain chemicals that control kind of happiness and sadness. And so the light exposure needs to be, it needs to be in your visual field. So you need to be actually looking at or working near the light box. And so you don't look directly at it, but you have it on when your eyes are open. I think a lot of people like to think that a tanning salon would help with light therapy, but tanning beds are not recommended for other reasons but because you cover your eyes they actually don't work at all for seasonal affective disorder. 3
All right. And these aren't terribly expensive, are they? No, they're not. There's a lot of different models you can get, and you can certainly look at them online, but they don't need to be expensive. Working with Your Doctor to Find the Best Approach for Treatment Dr. Wong, so someone comes to you--so, first of all, if they're feeling this way, if they're feeling blue, that's a reason to see your family doctor, right? That's a perfectly legitimate reason to come in. Definitely. I think what's important in terms of whether or not you go see the doctor is just whether or not you feel the need, and we're welcome and open to see patients for whatever concerns. All right. So someone comes in. They start talking about, so you said earlier first line might be, well, How active are you? Can we get you just taking a walk or did you go to the gym in the summer, whatever, could you go now. So exercise. And then we talked about the light box. Now, when do you decide with the patient, well, maybe--because you mentioned depression, we know millions of people take medication for that, that medication would come in or some kind of talk therapy. Dr. Wong, talk about where that fits in. Well, medications are definitely a big part of treatment for depression and SAD. I would leave it up to patient preference. Obviously if you have more severe symptoms or if you've tried light therapy initially and you don't feel like that's adequate, medications would be the next line. But some people who have maybe experienced this in the past or maybe they just feel like their symptoms are out of control or impacting their life to such an extent that they would like to try medications as a first-line therapy, that's also reasonable. And we have lots of experience with prescribing antidepressant medications, and they're a very safe class of drugs, so it is a very frequently prescribed method for treating depression and for seasonal affective disorder. Dr. Sheffield, so let's talk about seeing result. So if I come to you, and I understand as a UW Medicine patient I can even--there are ways, secure ways of e-mailing you too, and communicating with the team. Is that right? Yeah, that's right. We have a secure web portal that's called the ecare, and that way our patients can communicate with us online. 4
Okay. So let's say I've come to see you, and maybe exercise is an approach or light box, and I'm going to write you and I'm going to say, well, gee, Doc, when am I going to start to see some results? How quickly do some of these approaches make me feel better? You know, some people respond really quickly to light therapy. Sometimes within just a few days they'll notice a lightening of their mood and then an improvement. For some reasons for some people it can take a couple weeks or even a few weeks, so we definitely would want to give it some time as long as the symptoms weren't severe, somewhere in the range of three to six weeks. And at that point if things aren't getting better then it's time to think about other therapies. Now, that being said, you know, depending on how much this disorder is affecting your life we might want to act a little faster. Now, Dr. Wong, I understand there can be other forms of depression that we need to kind of sort out. It could be SAD, but it could be something else. What would be an example of another one that would be handled differently? Well, SAD is a subset of depression. It can also have a--be a seasonal component of other disorders such as bipolar disorder. Bipolar disorder is an interesting medical condition that can sometimes mimic depression but have some subtleties that don't show up initially. So that's why we would encourage patients that have severe symptoms or patients that are not responding to, let's say, light therapy at home, to come in to discuss their symptoms with their provider because then we can ask some specific questions, do some other assessments, to see if there could be a different condition present than just depression. How SAD Can Affect Your Life Dr. Sheffield, when someone has SAD how would it affect their life? So we talked about eating, sleeping more. What about on the job? Would they just feel sort of listless on the job? There's a couple of things that can affect job performance. Certainly people feeling tired, you know, sleepy is going to affect their job, but people also will often feel irritable and sensitive to criticism, and so those are the types of things actually that tend to come through at the job more. You know, that reactivity. Your boss gives you some feedback and you're either crying or yelling, and so this can really significantly affect people's work life. What about relationships? Will SAD make you more irritable, you're fighting with your partner, or family or friends? You're just edgy. 5
Yeah, absolutely. And one of the things I notice when treating depression in general is that I can spend an hour with a patient first presenting with me for depression and that patient can spend an entire hour explaining to me why the way that they feel is perfectly logical because it's someone else's fault. So they may spend an hour telling me how annoying their partner is, how annoying their boss is, someone at their workplace. And after they get effective treatment I'll go back and say, Well, what about your partner or your boss or your colleague? And they'll say, Well, you know, actually they're not that bad. So brain chemicals really affect our perception of our world, and it's very fascinating to watch how people's perception of the situation they're in can change completely once their brain chemicals are back in the normal range. The Role of Vitamin D I want to talk to you, Dr. Wong, about sunshine. So my understanding is living in the Pacific Northwest or other northern climates we may very well be vitamin D deficient, and I know for some conditions people even take supplements of vitamin D. Does that play a role at all in SAD, or that's not relevant? Well, it is true that most people that live in the Pacific Northwest are vitamin D deficient, and that's because vitamin D is synthesized by your skin when it is exposed to sunlight. In the past there were hypotheses that vitamin D could play a component in mood regulation and that vitamin D would be an effective treatment for people who are depressed or have other mood problems. However, the medical literature has really been inconclusive about this. Whenever we talk about supplements or natural therapies we always approach it as a risk versus benefit. And so the benefits of vitamin D are obviously bone strength, increasing your calcium absorption. Those are definitely known benefits of vitamin D. But it's sort of hit or miss, depending on the studies you look at regarding mood and vitamin D. However, the risks of taking vitamin D are very low. It is rare to get vitamin D toxicity, so if you feel like vitamin D plays a big part in making you feel better regarding your mood, it's okay to take it as long as you're taking it as directed from the supplement standpoint. However, it's not something that I routinely prescribe to people who are having mood problems because the medical literature has just been inconclusive. Dr. Sheffield, when we introduce supplements into the discussion, that's something that should all be disclosed to your primary care doctor, right? That's part of the discussion. I went to the health food store and I bought this and I'm trying that. You want to know everything somebody is taking and certainly if then you start to introduce any prescription medicines you need to see the whole landscape, right? 6
Absolutely, yeah. And some supplements actually mimic or even contain some prescription medication ingredients, so we definitely want to know all the different supplements that our patients are taking before we prescribe a medication or just for their general health. A Prescription for Fun Dr. Sheffield, I read an article you wrote about seasonal affective disorder, and the last thing is you sometimes write a little prescription, if you will, a note for the patient that says be sure to have fun. Yeah. So where does fun--and I wonder, you know, we have a lot of people in Seattle if they can afford it, who try to take a vacation to some place sunny in the dead of winter. Yeah. Maybe it's even a ski resort where it's cold and sunny, but it's sunny and it lifts their spirits. So where does, talk about fun, talk about, if you can, taking a trip to someplace else. You know, fun is one of those things that, you know, is such a simple, basic thing to human nature, and it's amazing how in our modern lives we forget to schedule in something fun. Like I said this time of year people have so many responsibilities, they're busy with so many things and just forget to schedule some time for themselves. So I think it's really important to schedule, schedule yourself something that you enjoy, something that's just for you. And I think particularly in this climate it's really good to, it's really good to get outside, so that's where going up to the mountains and getting in the snow or, you know, taking a sunny vacation. One of the things I'd warn about sunny vacations is actually the Pacific Northwest has a pretty high incidence of skin cancer, which is interesting because we think that we are immune to it because we don't get a lot of sun. So some of those sunny vacations might be contributing to that. So take the sunny vacation, just take a hat. All right. And certainly if you go to Hawaii if you can afford it, or go to Palm Springs, someplace like that, you've gotten on a plane, sunscreen. So it's a whole balancing act. 7
Dr. Wong, so we're at holiday time as we record this program, and often there are social interactions, parties, open houses, things like that that happen. Someone with SAD might first feel not like going. Do you encourage people though to get out? That the social interaction can help? Well, it's always good to have a routine, you know, something to motivate you to get out of bed, to be productive. That has definitely helped in morale and in mediating symptoms. I think I would tell my patients that it's good to socialize and get support from your friends, but you also need to balance that with how much stress you're under. As Dr. Sheffield mentioned, this is a very stressful time of year, so it is good to interact with friends and gain support, but it's also, you know, if that family gathering or if that social event is going to just make you incredibly anxious or stressed out you might want to pass and replace that with exercise or something that's pleasurable or relaxing to you. SAD Can Be Cumulative or Immediate Good point. Dr. Sheffield, so is seasonal affective disorder or the likelihood of experiencing it cumulative? So I've lived in Seattle 23 years, our producer, Thea, has lived here her whole life, and so we wonder with each passing winter season of darkness are we more likely to have it. Is there any evidence there? You know, there is some question about that, whether people who live in a dark area longer may have more, more tendency to develop seasonal affective disorder. It's kind of an interesting disorder because you can't diagnose it in one season. The only way you can diagnose it is to see a pattern over multiple years. There is also some evidence that people who lived in a sunny area and then moved to a higher latitude may be more prone to seasonal affective disorder. Wait a minute. So if somebody is transferred to our area from California, Southern California, they've been playing volleyball on the beach, in the sun, and then they're transferred up here, they have a great job but then winter hits, so they might be more susceptible? Yeah. They may be more susceptible to having a seasonal depression. So those are people I always check in with a lot, those transplants from Arizona or California and say, How is the winter going for you? All right. Dr. Wong, so you encourage people to call if they're concerned. You're happy to see them. And then you're happy to discuss with them and work with them whether it's a first--what's the accurate diagnosis, and then these different strategies you mentioned, exercise, light, maybe counseling, prescription medicine, that happens in a dialogue with 8
you. Correct. The Importance of Getting Help Okay. Dr. Sheffield have you--of all the things that you deal with, it sounds like this is pretty treatable. There is literally light at the end of the tunnel for people, that if someone is down, and here we go again with winter, and it happened last year and it's just something that just weighs on them, do you have a lot of hope and solutions for them? Absolutely. And I think that my job as a family doctor is really to give people that hope because one of the symptoms of depression is hopelessness. So people who come in with these types of disorders feel hopeless as a symptom of their disease. And so one of the things that's most important to me that I always make sure I say to my patient is, I am going to help you feel better. You are going to feel better and you need to just take my word for it because of my experience that this is going to get better. And that's something I do for people who have seasonal depression and depression in general because it's a hopeless feeling to have, and so giving them back that hope is a big part of our job. Dr. Wong, you'd echo that as well? Oh, definitely. We have so many modalities for treating depression. And, you know, a big part of it is just to feel acknowledged and to feel heard and have someone take you seriously. And so typically when we start treating someone for a mood disorder, whether that's depression or anxiety or SAD, you know, we see them frequently, we make ourselves available, and we reassess. We're constantly checking on the patient to see if they're responding well to therapies, and if they're not we look for something that will work because there is something out there. Dr. Sheffield, I understand that SAD can be--and depression in general can be more common in women. Do we have any idea why? Wow, that's a great question. Women's lives are harder, don't you think? Well, I'm not sure, but I'm sure you can tell me. Often women are worried about the rest of the family. Whether they have children or an aging parent, they're looking out for everybody else, and certainly at this time of the year they may be involved in a lot of 9
arrangements for all sorts of things. So this is not, though, something that somebody should be embarrassed about. Not only should they seek care, it's not something to joke about, it's something to get help for, right? Absolutely. And I think--you know, I see a lot of women and women are the caregivers and women are so good at putting themselves last. And I do think that that kind of pattern of putting yourself last and taking care of everyone else first contributes to--contributes to depression for the reasons that we have kind of discussed, is not taking the time to exercise, not eating right, not including things in your day that are fun for you. And so part of that prescription for fun that I give patients is a lesson in taking care of yourself. And sometimes with women the only way I can get them to do it is to tell them that if they don't take air of themselves they're not going to be well enough to take care of the rest of the family. And sometimes that will--that will motivate them enough to start taking care of themselves. Well, we've covered a lot of ground. So here we are with darkness. We can look forward to spring, but there are answers. And again, Dr. Wong, you're happy to discuss this and be a partner with someone at the UW Medicine neighborhood clinics to help them get through it, right? Definitely. Okay. All right. I want to thank you so much for being with us. Dr. Crystal Wong at the UW Medicine neighborhood clinic in Ravenna in Seattle, and also the chief there, Dr. Pamela Sheffield. Ladies, thank you so much for being with us on Patient Power. Thank you for having us. My pleasure. This is what we do on Patient Power is really talk about things that could affect your family, could be affecting you and when we talk about seasonal affective disorder there are strategies to help you feel better. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion your own doctor, that s how you ll get care that s most appropriate for you. 10