Unlocking the Unique Aspects of Seasonal Affective Disorder for Better Patient Support This Winter

President-Elect of the American Psychiatric Association, Ramaswamy Viswanathan, MD, DrMedSc, recently spoke with Psych Congress Network about what clinicians need to know about Seasonal Affective Disorder (SAD), and how to better support patients experiencing symptoms. SAD, a form of depression typically linked to reduced sunlight during fall and winter, affects about 5% of US adults and lasts about 40% of the year.

Dr Viswanathan explores how the findings highlight the significant impact of seasonal transitions on mental well-being, emphasizing the need for awareness and targeted interventions for those susceptible to SAD-related challenges.

The APA’s recent poll, conducted in September 2023, found that 22% of adults report negative mental health impacts from daylight saving time changes in years past, with women (29%) and rural residents (28%) notably affected. Two-thirds of respondents notice behavioral changes with winter's arrival, including increased sleep (31%), fatigue (25%), and depression (23%).

Transcript:

Dr Ramaswamy Viswanathan: Hello everyone. I am Dr Ramaswamy Viswanathan. I'm the President-elect of the American Psychiatric Association (APA). I'm also professor and interim chair of Psychiatry and Behavioral Sciences at SUNY Downstate Health Sciences University in Brooklyn, New York.

Meagan Thistle, Managing Editor, Psych Congress Network (PCN): What factors contribute to the significant gender difference in negative mental health impacts from the fall time change, and how can clinicians address these disparities in SAD treatment?

Dr Viswanathan: Good question. Even though twice as many women report seasonal changes in depression compared to men, we also have to be mindful that this is the difference in the prevalence of depression in the general population in general. Thus, people are not sure really whether the changes in seasonal variation is a difference between the genders or if it is simply because twice as many women as men are depressed, and seasonal depression is simply one subtype of a major depressive disorder. So, it simply may not be a real difference at all.

Another view is more women than men are likely to report their psychiatric symptoms and seek psychiatric treatment. This partly can explain the increased prevalence of depression as well as seasonal depression in women.

In fact, one has to be mindful that not all mood changes are necessarily a depressive disorder. Many people experience mood changes that can lead to some distress and some impairment in function but do not race to the level of depressive disorder.

One also has to be mindful that there are other psychiatric disorders like mania and hypermania that can also be affected by the change of seasons. However, the most typical disorder is a major depressive disorder that is affected by seasons.

When we talk about seasonal affective disorder, we generally speak about major depressive disorder with a seasonal influence and people have to be questioned explicitly whether fall and winter make any changes in people's depressive disorder. If they don't, they have to be specifically asked about the different criteria which qualify for a depressive disorder.

Some of the symptoms in seasonal affective disorder are different than what we call typical depression and they go along more of what is called atypical depression. For example, people report hypersomnia increased sleep during winter, and also, increased appetite and eating. These 2 will be considered as atypical.

Of course, a prominent complaint is fatigue. People feel tired, and their attention is somewhat impacted. Even though not everybody has depressive disorder, but still in our current day world, the seasonal variations can have significant consequences. For example, if you [look at] driving, if there's some impairment of functioning and some sleepiness, that can lead to very serious accidents. This is one of the reasons we have to ask anyone if there are any change in their attention level or energy level.

Thistle, PCN: How can mental health clinicians discuss recognizing seasonal behavioral changes, with their patients, like increased sleep, fatigue, and depression, particularly for those without a formal SAD diagnosis?

Dr Viswanathan: That’s an important question. The first thing is that one needs to screen for seasonal changes in their patient's mental health. Most of the time, patients don't volunteer this information, so you are to ask them specifically. If you determine that somebody's alertness level or mood is affected by seasons, then depending upon how severe the disorder is—if it's mild or moderate—the most important things will be paying attention to are light exposure and also sleep hygiene, as well as exercise.

People should get out of the house and expose themselves to sunlight. That is way better than simply exposing oneself indoors. Even on a cloudy day, sunlight has as much light as what you can achieve maximally indoors with the current indoor lighting. Exercise outdoors has become important; exercise by itself is good for treating any kind of depression—it has a very powerful effect.

Sleep hygiene—it's a little bit complicated because in most parts of the world, there's daylight savings time, and then in fall and winter, we go back to the regular time. That also changes interface with the circadian rhythm. So, people have to practice sleep hygiene.

Also, if they have difficulty falling asleep, they have to ensure they are not stimulated by light for a couple of hours before falling asleep. This is the opposite of what we try to do in the morning wherein we actually encourage sunlight exposure.

Additionally, therapeutically, there are light boxes available. Typically, there are 10,000 lux, and that's an important intervention. Even if the health insurance companies don't pay for it, they're not that expensive. They cost about $70 and are readily available online. I encourage my patients to buy that. Another alternative is there are lights available that simulate dawn when you're waking up, and they are equally effective. One can do both—have a dawn simulation as well as the bright light exposure in the morning.

More severe disorders they need antidepressant medication, which can be done in combination with light and exercise as well as sleep hygiene. Cognitive behavioral therapy is also quite important in dealing with seasonal affective disorder.

Thistle, PCN: In light of the poll's findings, what strategies or interventions would you recommend clinicians engage with their patients to help mitigate the mental health impact of seasonal changes, such as the transition to winter and daylight savings time?

Dr Viswanathan: Yes, mood changes and anxiety. They are very prevalent in the population and we should always address them. And they not only cause distress, but they can also increase the risk of accidents and also contribute to medical comorbidity also. Part of that exploration also needs to involve whether changes in the season is affecting one's mood. Physicians also have to pay attention to the health habits of their patients,—sleep hygiene, exercise, nutrition—all of them have an enormous impact on both mental and physical health.

Thistle, PCN: Any final thoughts or takeaways?

Dr Viswanathan: I thank the Psych Congress Network for picking up this survey done by the American Psychiatric Association about important mental health issues, including this one on effect of a seasonal change on one's mood and other parameters like depression and fatigue and sleep. And this is obviously will get the word out given Psych Congress Network’s reach. This will help get the message to more people in the world. And that's very important because physicians and mental health professionals have to become aware of these issues.

Finally, the population needs to be aware of this because one can take effective steps to minimize any harm, distress, or inconvenience caused by these symptoms. So thank you for doing it.

Ramaswamy Viswanathan, MD, DrMedSc, served as elected Trustee of Minority and Under-Represented Groups on the APA Board in the years 2017-2019. He was a longstanding representative in the APA Assembly (1996-2017, 2019-2023), authoring several influential action papers, including one in the year 2002 foresightfully advocating for telehealth to improve access to care. In 2016-18 he was Secretary of the New York State Psychiatric Association (NYSPA). In the APA he has served as Chair of the Bylaws Committee, Vice-Chair of the Council on Member and DB Relations, APA’s representative on AMA IMG Section, and on Finance and Budget Committee, Council on Global Psychiatry, Committee on C-L Psychiatry, Nominating Committees, Assembly Committee on MOC, and Board and Assembly workgroups. He founded and conducted an annual RFM Posters contest for the thirty residency programs in New York State (2016-2023). He founded and conducted an annual Residents’ Scholarly Presentations contest for the 4 residency programs in the Brooklyn District Branch (1992-2023). He founded the APA Caucus on Maintenance of Board Certification. He is Chair, Committee on C-L Psychiatry, Group for the Advancement of Psychiatry. He is a past Chair, Finance Committee, Society for the Study of Psychiatry and Culture. He is a member of AAAP, AACP, AADPRT, AAGP, AAPL, ACLP, ACPsych, AMA, and Climate Psychiatry Alliance. Dr Viswanathan is Board Certified in Psychiatry, Internal Medicine, Consultation-Liaison, Geriatric, Addiction and Forensic Psychiatry. He is a tenured Professor and Interim Chair of Psychiatry, and Director of C-L Psychiatry and C-L Psychiatry Fellowship at the State University of New York (SUNY) Downstate Health Sciences University. He was the Presiding Officer of the Faculty and Professional Staff of the College of Medicine (2020 – 2022).