SAD - Seasonal Affective Disorder

Or Why You Get the Winter Blues…

Scott Carroll, MD

UNM School of Medicine

www.scottcarrollmd.com

Objectives

• How Seasonal Affective Disorder (SAD) differs from other mood disorders.

• What neurotransmitters and vitamins are associated with SAD.

• 3 non-pharmacological treatments that may be effective for SAD.

SAD – DSM 5 Criteria

• Mood d/o “with seasonal pattern”

• A – seasonal onset

• B – full remission/switch after season

• C – no non-seasonal episodes x 2yrs

• D – more lifetime seasonal episodes

• Not due to seasonal stressors

Winter Depression or Hibernation?

• Short, grey days

• Increased sleep

• Low energy

• Dep mood +/-

• Wt gain/crave carbs

• Isolate/low libido

Summer Depression or Hypomania?

• Long, sunny days

• Insomnia

• Anxiety

• Irritable mood

• Decreased appetite

• BPAD II is highly seasonal

SAD – Melatonin vs. Serotonin

• Melatonin – induces sleep

• Serotonin – alertness, mood

• Both made from tryptophan

• Alternate with each other

• Mel triggered by darkness

• NE suppresses melatonin

SAD - Epidemiology

• Alaska 9.9%

• Florida 1.4%

• AK subclin 24.9%

• Varies w/ latitude and cloud cover

Geographic Variation

• Ireland ~ 20%

• Netherlands ~10%

• Iceland ~1%

• Japan ~2%

• Genetic?

• Fish based diet?

SAD – Risk Factors

• Female > male (MDD form, not BPAD)

• Young adults > elderly (low melatonin in elderly?)

• Family history

• Mood disorder > no mood disorder

• High latitude/cloud cover > equator/sunny

• Sedentary > regular exercisers

• Recent move to higher latitude or a cloudy area

SAD - Pharmacologic Therapy

• Norepinephren inhibits melatonin secretion

• Bupropiron (Wellbutrin/Zyban)

• Modafinil (Provigil) and (probably) armodafinil (Nuvigil)

• Atomoxetine (Strattera)

• Stimulants (methylphenidate and amphetamine)

• SNRI’s and SSRI’s

• Caffeine

Non-Pharmacologic Therapies

• Dawn/sunlight exposure (windows, going outside)

• Exercise (outdoors during daytime is best)

• Full spectrum light box at > 10K lux (blue or blue-green?)

• Cognitive-behavioral therapy (CBT)

• Negative air ionization therapy at high density

• Combination therapy

Alternative Treatments

• Melatonin

• Vitamin D

• Saint John’s Wort

• SAMe

• Fish oil/omega 3 fatty acid (or eating more fish)

• Travel to a sunny location

Fall/Winter BPAD Treatments

• Optimize mood stabilizers (esp. Lithium and Lamictal)

• Increase sunlight exposure especially at dawn

• Full spectrum light box (30-60 min every morning)

• Melatonin (3-6 mg every night)

• Fish oil (1K to 2K mg twice a day)

• Vitamin D (400 to 1K international units per day)

• Thyroid supplementation

Spring/Summer BPAD Treatment

• Blackout curtains and eye mask

• Melatonin

• Optimize sleep medications

• Optimize mood stabilizers (add antipsychotic?)

• Fish Oil

• Thyroid supplementation

• Vitamin D

Reversed BPAD Seasonal Pattern

• ~ 10 – 15% of BPAD w/seasonal pattern

• Confirm true reversed pattern

• Optimize mood stabilizers (Li and Lamictal)

• Melatonin

• Optimize sleep meds

• Fish oil and Vitamin D

• Thyroid supplementation

More Info At…

• www.mayoclinic.org

• Wikipedia

• www.webmd.com

• My slides are on Slideshare.com, search for Scott Carroll

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