Department of Psychiatry University of British Columbia Seasonal Affective Disorder Dr. Erin Michalak Sauder School of Business 5 th Annual Health and Safety Day October 21 st 2009
UBC
Talk outline What is SAD? Seasonality? How can it be treated? What self-management strategies are likely to be effective?
SAD: DSM-IV Diagnosis Course Specifier - Seasonal Pattern Major Depressive Episode Regular episode onset at a particular time of year Full remissions or switch at regular time of year 2 seasonal episodes in past 2 years Sub-syndromal SAD (S-SAD) is a milder variant of SAD
How Common is SAD in Canada and the U.S.? 1.7% Levitt et al 2.7% 2000, 2001 0.4% Blazer et al, 2000 (NCS) 600,000 to 950,000 Canadians affected by winter depression
Increased appetite Carbohydrate craving Weight gain Lack of energy Slowed down Increased sleeping Increased need for sleep
Vancouver SAD Clinic 1990-1998 Symptom Profile N=454 patients, DSM-III-R / IV Increase Decrease Sleep 71% 26% Appetite 57% 28% Weight 53% 14% CHO craving 77% Anxiety 79% (12%) Suicidal 47% (10%) Lam RW, Primary Care Psychiatry, 1998
Effective Light Therapy NOT changing kitchen lights NOT tanning studios NOT special type of light
Intensity LUX = PHOTOMETRIC UNIT Evening home lighting: < 100 lux Office: 300-500 lux Cloudy day: 3,000 5,000 lux Direct sunlight: >50,000 lux
Fluorescent Light Boxes
LED technology, White light, no UV Very portable www.litebook.com
% Clinical Response Light Therapy is more effective than Placebo for SAD 60 50 40 30 20 10 Morning Light Evening Light Placebo All p<0.05 0 Terman (N=144) Eastman (N=96) Terman M, et al. Arch Gen Psychiatry 1998, 55:875-82. Eastman C, et al. Arch Gen Psychiatry 1998; 55:883-89.
Light Therapy: Side Effects Headache Feeling wired Eyestrain No evidence of toxicity or eye damage with light therapy Nausea/dizziness Hypomania
% Clinical Response SSRIs are more effective than Placebo for SAD 70 60 * * Antidepressant Placebo 50 40 30 20 * p<0.05 10 0 >50% Ham-29 Fluoxetine 20 mg/d 5 weeks, N=68 CGI=1,2 Sertraline 50-200 mg/d 8 weeks, N=187 Lam RW et al, Am J Psychiatry, 1995; Moscovitch A et al, Psychopharmacology, 2004
CAN-SAD Study 2000-2003 Raymond W. Lam, Anthony J. Levitt, Robert D. Levitan, Murray Enns, Rachel L. Morehouse, Erin Michalak 4 centres across Canada Vancouver, Winnipeg, Toronto, Saint John Light therapy vs. fluoxetine 96 patients with SAD over 3 winters 8 weeks of treatment Multiple outcomes and predictors symptoms, quality of life, genetics, personality, circadian Funded by CIHR
Mean Change from Baseline in Ham-24 Score CAN-SAD Study Light Treatment vs. Fluoxetine in SAD 0 0 Week 1 2 3 4 5 6 7 8-4 -8-12 * Fluoxetine (N=48) Light Treatment (N=48) -16-20 *p 0.01 vs. fluoxetine ITT, LOCF Lam RW et al, Am J Psychiatry, in press.
How do you choose: Light or Drugs? Consider Light Therapy when: More or less severe Risks for drugs Side effects to drugs Motivated for light Atypical symptoms Cost of drugs Patient preference Consider Antidepressants when: More or less severe Risks for light Side effects to light Convenience important Typical symptoms Cost of light device Patient preference Lam & Levitt, 1999, 2004 Note: None of these factors is absolute
Self-management strategies education Education yourself about the treatments, course and risk factors for SAD UBC Mood Disorders Centre SAD information page (www.ubcsad.ca) SLTBR website (www.sltbr.org) Canadian Mental Health Association (www.cmha.ca) Mood Disorders Association (http://www.mdabc.net) Learn about CBT for winter depression (see Coping with the seasons: A cognitive-behavioral approach to SAD 2008 Rohan, K. Oxford University Press)
Education learning more about winter depression Comprehensive overview of SAD treatments and selfmanagement strategies Excellent workbook on CBT techniques for depression Guide for clinicians on using light therapy
Studying your mood patterns Life Charting - the helicopter view
Life Charting Severe Mania Hypo-mania (moderate mania) March 1991 April 1995 Aug 1995 - Nov 1996 Mild Mania Mild Depression Oct 1990 June 1995 Moderate Depression Severe Depression Dec 1990 Nov 1991 Life Events Finished high school Left home for college Finals very difficult Stress around school Relationship breakup In recovery Medications Untreated- no medication Mood stabilizer & antipsychotic Added Antidepressant New mood stabilizer Lithium restarted & antidepressant Lithium and l Risperidone School/Job Enrolled in high school First year in College In College Second year Third year in college Break from school Finished college (Fall 1996)
Seasonal charting Your own responses to the changing seasons are to some extent predictable Work on identifying your early warning signs for an oncoming episode Many individuals experience changes in sleep/energy first, followed by appetite/weight, then mood Techniques: 1. Card sorting exercise early, middle, late symptoms 2. If retrospective recall is difficult, measure symptoms over time, may help to use a daily mood chart
Daily mood chart, from Winter Blues (2006)
Daily mood chart bipolar disorder version M A N DYSPHORIC MANIC ( ) IF YES SEVERE Essentially incapacitated or HOSPITALIZED HIGH MODERATE Great difficulty with goal-oriented activity I A D E P R E S S I O N LOW MODERATE SOME difficulty with goal-oriented activity MILD More energized & productive with little or no functional impairment STABLE MILD Little or no functional impairment LOW MODERATE Functioning with SOME effort HIGH MODERATE Functioning with GREAT effort SEVERE Essentially incapacitated or HOSPITALIZED MOOD (0-100) 0..50...100 More depressed over balanced most manic (activated) ever NUMBER OF MOOD SWITCHES/DAY MENSTRUAL PERIOD ( ) IF YES 49 50 50 40 40 38 36 34 30 30 30 45 50 50 55/ 60/ 81 79 89 90 90 80 80 55 55 45 45 39 35 41 40 20 20 3 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DBSA http://www.dbsalliance.org
Prevention/intervention strategies Plan your prevention/intervention strategy in advance Consider: What self-management techniques have worked for you in the past? How severe is your SAD? What is the normal course of your SAD? (prevention vs. intervention strategies) Example self-management strategies: Plan an exercise/dietary program (maximise outdoor exercise when sunny) Manage stress as effectively as possible Communicate with friends/family/co-workers about your seasonality Plan winter breaks where affordable/feasible Engage in CBT techniques, for example, pleasurable activity scheduling
Scheduling pleasurable activities Day of the week and target time Monday 1 Scheduling Pleasurable Activities Pleasurable Activities Actual time each activity was done Mood before and after each activity (-3/+3) 1 3 pm Take the dog for a walk 1 3 pm -2-1 2 2 8 pm Visit Brenda 2 8.30 pm -1 +1 Tuesday 1 1 1 2 2 2 Wednesday 1 1 1 2 2 2 Behavioural activation and maximising ROUTINE
Things to watch out for. CBT teaches you to challenge negative thoughts about winter, low light levels, weather etc
LIFE Trial, 2009-2013 Light, Ion and Fluoxetine Efficacy in Nonseasonal Major Depression Investigators: Raymond W. Lam, Anthony J. Levitt, Robert D. Levitan, Erin E. Michalak, Murray W. Enns, Sagar V. Parikh, Amy Cheung, Alex Kiss, Serge Beaulieu, Rachel L. Morehouse, Raj Ramasubbu, Glenda MacQueen. 6 centres across Canada Vancouver, Calgary, Toronto x 2, Montreal, Saint John Light therapy, negative ions + fluoxetine combinations 216 patients with MDD 8 weeks of treatment Multiple outcomes and predictors Symptoms, side effects, quality of life, chronotype, health economics Funded by Canadian Institutes of Health Research
Feel free to contact me! erin.michalak@ubc.ca