Bright Nights Community Forum

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Bright Nights Community Forum

• Seasonal Affective Disorder
• University of Michigan Depression Center
• Ann Arbor Public Library

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Bright Nights Forums

• U-M Depression Center and Ann Arbor Public
  Library
• Presentation on topics of interest relevant to
  mental health in community
• Panel of experts from U-M Depression Center and
  Professionals in community
• Q/A format
• Improve community awareness of resources
  available.

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Bright Nights Forums

• Bipolar Disorder March 29th
• Suicide May 24th

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Seasonal Affective Disorder

• What is Seasonal Affective Disorder - SAD
• The formal Diagnosed syndrome
• Sub-syndromal SAD
• Hypotheses surrounding SAD
• Research relevant to SAD
• Treatment options
• Physical Treatments
• Medication
• Panel Discussion

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On the treatment of disorders of mood.
Live in rooms full of light Avoid heavy food Be
moderate in the drinking of wine Take massage,
baths, exercise, and gymnastics Fight insomnia
with gentle rocking or the sound of running
water Change surroundings and take long
journeys Strictly avoid frightening ideas
Indulge in cheerful conversation and amusements
Listen to music.
Cornelius Celsus (first century AD)
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What is SAD?

• SAD Seasonal Affective Disorder
• Affective Disorder that occurs predictably at a
  specific season - most frequently in the fall or
  winter months.
• Affective Disorder is used interchangeably with
  Mood Disorder and usually refers to depression.
  

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Understanding Affective Disorders

• Kraepelin proposed affect to consist of 3
  components
• Volition
• Energy Drive
• Emotion
• Happy / Sad
• Intellect
• Rate of thoughts
• Content of thoughts

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Affect - Affection
Volition the drive to care for our
offspring Emotion the love for our
children Intellect the thoughts speech
related to our interactions with family and loved
ones
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Normal Affect
- Moods and disposition fluctuate over time
Volition
Emotion
Intellect
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Depression
Volition
Emotion
Intellect
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Affect and Affective Disorders

• Volition drives energy levels
• Depression - lowered
• Emotion mood (happy vs sad)
• Depression sad low guilt
• Intellect thinking
• Depression decreased rate - negative

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SAD - clinical features

• Clinicians refer to atypical depressive sxs
• Sleep hypersomnia - too much sleep
• Difficulty getting out of bed
• Slow to get going
• Fatigued throughout the day
• Atypical because majority of depressed patients
  experience difficulties sleeping (frequent
  awakenings during the night or awakening more
  that 1 or 2 hours earlier than custom).

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SAD - atypical features

• Appetite Increase (hyperphagia)
• Carbohydrate craving
• Comfort eating / grazing
• Eating at non-meal times
• Atypical because most people with depression
  experience decrease in appetite.

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Sub-syndromal SAD

• Winter Blues - Winter Doldrums
• Common 10 - 25 of middle latitude population
• Defies a clear definition.
• Does not meet diagnostic criteria for Depression
• Milder form of SAD with distinct discomfort and
  qualitative change in functioning (decrease) and
  activity level
• Slowed down / Irritable
• Some symptoms of atypical depression
• Over-eating Over-sleeping

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SAD - Research

• Epidemiology
• SAD 1-3
• Sub-syndromal SAD (Winter Doldrums) 25
• Chronic Course - 40 with seasonal pattern at 10
  year follow-up 40 became non-seasonal.
• High association with eating, anxiety, and
  substance abuse disorders.
• Associated with higher latitudes.
• Middle latitudes (such as Michigan !)
• Extreme northern latitudes show lower frequency

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SAD ResearchCircadian Rhythms

• Photoperiod hypothesis
• The shorter winter photoperiod results in SAD.
• Northern latitudes, controverted findings
• Melatonin secretion longer during winter in SAD
• Artificial light treats SAD
• Phase-shift hypothesis
• Phase delay of circadian rhythm relative to
  external clock waking later into evening and
  arising later in morning.
• Light therapy in am causes phase advance -
  correcting phase delay.

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SAD - Genetics

• Individuals with SAD frequently have family
  history of Depression (2/3) or SAD (1/3).
• Are there genetic variants that predispose to
  depression and SAD?
• Class of genes - circadian clock genes have
  shown association with SAD.
• Are there genetic variants of these clock genes
  associated with SAD.
• Preliminary evidence suggests this but not always
  replicated in independent studies.
• No specific tests to diagnose SAD.

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Controversies in SAD

• Phase delay / advance studies of circadian rhythm
  require rigorous monitoring of body chemicals,
  sleep EEGs, temp, etc.
• Small numbers of individuals studied
• Conclusions often conflict
• Conflicting results of effects of light therapy
  on phase change.
• Phase advance not always associated with clinical
  improvement.

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SAD - treatment

• Light therapy
• 30 min per day
• Begin with AM light
• 10,000 Lux
• Specialty light box
• Medication.
• Usually required for major depression with
  seasonal pattern
• (10 - 15 respond to light alone)

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Sub-syndromal SAD

• Light therapy alone often lifts the
  winter-blues
• Ok for individual to buy box on own accord, buy
  from established company.
• Follow instructions
• Consult physician if taking medication.
• Some medications cause light sensitivity.

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Let there be light.
Any light box you buy should have been tested
successfully in peer-reviewed clinical trials.
The box should provide 10,000 lux of
illumination at a comfortable sitting distance.
Product specifications are often missing or
unverified. Fluorescent lamps should have a
smooth diffusing screen that filters out
ultraviolet (UV) rays. UV rays are harmful to the
eyes and skin. The lamps should give off
white light rather than colored light. "Full
spectrum" lamps and blue (or bluish) lamps
provide no known therapeutic advantage. The
light should be projected downward toward the
eyes at an angle to minimize aversive visual
glare. Smaller is not better When using a
compact light box, even small head movements
will take the eyes out of the therapeutic range
of the light.
Center for Environmental Therapeutics -
www.cet.org
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Review of studies 1975 - 2003

• 20 studies reviewed for efficacy of light therapy
  in SAD.
• Very strong effect-size for light therapy
• SAD
• Non SAD depression

Golden et al, Am J Psych. 2005
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Activity level improves using 4 weeks of Bright
Lights
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Side Effects of Bright Light

• Possibility of .
• Sleep disturbances
• Irritability
• Headache
• Eye irritation
• Marginal increase (but not significant) compared
  to control group.

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SAD - Conclusions

• SAD - refers to a seasonal pattern occuring in
  individuals with major Depression
• Symptoms are often atypical
• Increased appetite and over-sleeping
• Sub-syndromal SAD is common
• Noticeable qualitative change in functioning
• Light therapy is useful in treatment of SAD
• Effects noticeable within 2 weeks
• Difficult to establish routine of using light
  therapy.

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Panel Members

• John Greden, MD
• University of Michigan
• Randy Nesse, MD
• University of Michigan
• Tom Zelnik, MD
• St Josephs Medical Center
• Julie Kuebler, RN, NursePractioner
• University of Michigan
• Laura Nitzberg, LCSW
• University of Michigan