Winter Blues: Seasonal Affective Disorder (SAD)

Winter Blues: Seasonal Affective Disorder (SAD)

Seasonal Affective Disorder (SAD)

Depression can occur at any time of year. However, for many, winter represents the most vulnerable time. Changes in sunlight, temperature, changes in the brain and body’s internal chemistry, and the stress of the Holidays can all play a role. In some ways, Winter Depression is built into our biology – just think of bears that hibernate during the winter. Indeed, symptoms of winter depression can mimic hibernation, with lack of energy, sleepiness with difficulty getting out of bed, and an increased appetite with carb-cravings. Difficulty with concentration and focus can also be a symptom. Because of the physical symptoms, some describe seasonal affective disorder (SAD) as “vegging out.”

Some individuals only experience depression during the winter while others may experience it any time of year but more so during the winter.

Some specific findings associated with winter depression include:

1) Lower available levels of the brain chemical messenger serotonin. There is evidence that serotonin remains less available to stimulate neurons for people with SAD. This is because after serotonin is released from a neuron, thereby making it available to attach to and activate docking stations (known as receptors) on surrounding neurons, it is sucked back in by the releasing neuron too quickly in people with Seasonal Affective Disorder (SAD).

2) People with SAD may make too much melatonin, a hormone that promotes sleepiness. Excess melatonin levels can cause daytime fatigue. This can also throw off a person’s day-night cycle (circadian rhythm).

3) Insufficient Vitamin D levels may play a role in SAD. Vitamin D may be involved in the action of serotonin.

4) Activity of a structure deep in the brain called the hypothalamus may be uniquely sensitive to sunlight in people with SAD. The Hypothalamus controls sleep and appetite, and also may play a role in mood.

Treatment for Seasonal Affective Disorder (SAD):

First, it is important to rule out other possible causes, such as low thyroid or anemia as examples. I have had a number of patients where these were uncovered as causes of fatigue.

Very effective treatment for SAD is available. Bright Light therapy, Cognitive-Behavioral Therapy (CBT), and antidepressants are the most evidence-based. These and others that are often helpful are listed below.

Bright Light therapy

There are lots of different styles and price points of bright light lamps or boxes. Specific levels of luminosity (often 10,000 lux is recommended) and timing of bright light are important components. The timing of bright light may depend on the type of depression. For pure SAD or winter worsening of depression, the morning is usually best. Morning bright light resets circadian rhythm, activates the hypothalamus, and suppresses melatonin secretion. Melatonin release is regulated by light. Melatonin is always primed to be released in the brain but held back or suppressed by bright light. This is why melatonin is released at night (and also why you shouldn’t bring your phone or laptop into bed at night!).
(Note that although using bright light later in the day can make SAD worse by messing up circadian rhythm, there are always exceptions. I occasionally find that bright light later in the day whether exclusively or in addition to morning light paradoxically is more beneficial. Also, mid-day bright light is better for Bipolar depression).


Many antidepressants are used for winter depression but one is specifically FDA approved for it. However, your doctor needs to make sure this is the right antidepressant for you (for example, it’s not as good for some symptoms of depression or anxiety).

Cognitive-Behavioral therapy (CBT)

This can help change unhelpful behaviors and negative thinking, help change perspectives on the winter, and teach stress-reduction techniques.

Exercise. For those who are not inclined towards exercise, thinking of this recommendation simply as “getting the blood flowing” can be helpful, as even 10 minutes of physical activity a day can be beneficial. Outdoor activities can be especially helpful.

Vitamin D. Consult your doctor for Vitamin D dosing for SAD.

This article was originally published on Dr. Neal Ranen, Baltimore Psychiatric Services

Symptoms to Warrant a Psychiatrist Evaluation

Symptoms to Warrant a Psychiatrist Evaluation

These Symptoms May Warrant an Evaluation by a Psychiatrist in Baltimore

Life’s changes and challenges often make many people feel overwhelmed. Obstacles and circumstances can cause a stir of emotions or changes in attitude that can be difficult to understand and even more difficult to explain. There is a chance that negative thinking and an overflow of mixed emotions will vanish with time. Then, there are instances where these feelings linger, perhaps even for months or even years. It is then that a closer look or examination of the mental state must be taken. Even one to two weeks of a number of symptoms occurring at the same time, like changes in mood, sleep, self-attitude, energy level, anxiety level, behavior, and mental sharpness can indicate a psychiatric condition amenable to treatment.

Self-diagnosis is not uncommon, as is the view that challenges or changes will simply rid themselves. Symptoms might be explained away, even when the person has had similar recurring feelings in the past under completely different circumstances. Failure to identify symptoms and diagnose the core of the problem can easily lead to more severe, recurrent, and sometimes dangerous consequences. Failure to identify symptoms and diagnose the core of the problem can easily lead to more severe and recurrent consequences.

Mental distress is more common now than ever before. Research and treatment is widespread and ongoing. Psychiatrists have various approaches based on the dynamic of the illness. The key is to notice the symptoms and not ignore them, and then move forward to have them assessed.

Here are 5 signs that an evaluation by a psychiatrist is warranted:

1. Excessive fatigue or depression:

It is common for changes and unexpected occurrences in life to sometimes cause a downward shift in feelings. The need to compete for positions, attention and social status is a feeling that can easily get people down. This can contribute to becoming depressed or overwhelmed. These feelings can also come out of the blue, even when things objectively are going pretty well in the person’s life. Symptoms that come out of the blue can be associated with a family history of depression or other mental health conditions. The depression can be accompanied by low self-esteem, loss of appetite, decline in mood, hopelessness, irritability, and loss of interest in activities that were previously enjoyed. These are things that can lead to problems at work and with relationships, negative feelings about life, and much more. They make life feel difficult to enjoy, and everything may feel effortful. A psychiatric evaluation will assess these signs of depression.

2. Thoughts that life isn’t worth living:

Some who are depressed feel that they just want to run away or escape. This can take on a stronger tone of someone wishing they wouldn’t wake up the next morning, that they would just be taken in their sleep. Some express that they’re a burden and no longer feel needed on this earth. These are referred to as passive death wishes. Others have specific thoughts of ending their life by their own hands. It is important to take any mention of suicide seriously. An evaluation by a psychiatrist would be recommended in this case. (*Of course, any discussion of this topic warrants noting that with any immediate safety concerns the person should seek out care in the emergency room or call 911).

3. Emotional distress, altered moods, risky conduct, and strong emotional actions:

People who display frequent or constant changes in mood, emotional turmoil, signs of distress, and engage in frequent self-defeating or risky behavior may be displaying signs of mental illness. These signs may be sporadic and brushed off by the individual, or have already escalated to obvious levels of severity. In either case, a psychiatric evaluation should be pursued to rule out or diagnose a mental illness.

4. Constant Worry, Anxiety, or Panic Attacks:

These can occur in the context of different actual stress levels:

a) Regular everyday stressors but constant or disproportionate worry about them.
b) An elevated but not extreme increase in stressful circumstances but with an all-encompassing worry about them. There may have been a bothersome situation that others are telling the person to just put behind them but that they just can’t shake.
c) Objectively extreme high-stress levels causing constant fear and worry. This can be issues at work or in an individual’s personal life and can include traumatic events. Interestingly, a research article was just published showing that treatment with a well-tolerated group of medication, the SSRI’s, after a traumatic event can reduce the likelihood of certain general medical problems in the future. This certainly shows a mind-body connection, and further emphasizes the importance of psychiatric care.
d) Generalized anxiety and panic attacks can also come out of the blue. Anxiety or panic can even wake a person from sleep.

Regardless of the context, the symptoms of constant worry, anxiety or panic are treatable and an evaluation is highly recommended. Both psychotherapy and medication can be effective, and a psychiatric evaluation can best determine what approach or approaches would be best suited for the person.

5. Constant irritability or anger attacks:

Some people seem to have a naturally aggressive disposition that is easily set off by the simplest things. Others find they are constantly irritable out of character for them. Sometimes there are major things going on in the person’s life that are triggering these feelings and behaviors, and at other times they are in reaction to normal everyday circumstances. The reactions may seem warranted to the individual in response to others who have crossed them or unfair situations but are seen by others as unhealthy or disproportionate. Loved ones or friends may be afraid to point out the problem out of fear of becoming the focus of anger — they may find they are walking on eggshells. The irritable person may not recognize the problem because their reactions can seem justified to them. On the other hand, the person may hate that they are feeling irritable all the time. In any case, these emotions and behaviors can cause harm to relationships, or put jobs and careers at risk. And, the irritable or angry person, again, may themselves feel lousy most of the time and are not necessarily dealing effectively with situations. In addition, anger causes unhealthy physical stress reactions in the body, including in the cardiovascular, nervous and immune systems. An evaluation by a psychiatrist could identify if there is an underlying issue and determine what method of treatment would be most effective.

Of course, there are many other conditions that benefit from care from a psychiatrist, such as OCD and ADD/ADHD! Please see my previous blogs and information under “Conditions Treated” on the website for more info on these and others!

Unfortunately, it often isn’t until signs and symptoms such as the ones listed above have spiraled out of control that people begin to seek answers. This can be because of denial (recognizing but explaining away, or not themselves recognizing a problem) or stigma. It is obviously critical to seek care at that point, but it is also really important to proactively seek out an assessment by a psychiatrist before symptoms reach that level. We often refer to medical conditions as “disease,” that at its root means lack of sense of ease (“dis” “ease”), connoting that with these conditions there is a level of distress, or that things just seem so effortful. Psychiatric care aims to rectify this, alleviate symptoms, improve quality of life, and get to the root of the problem to prevent recurrences.

This article was originally posted on Dr. Neal Ranen M.D.

Photo Copyright: bialasiewicz / 123RF Stock Photo

Antidepressants Work!

Despite publications and media attention to the contrary, those of us in clinical practice, as well as our patients, have no doubt that antidepressants work. Confusion may arise because of the nature of FDA Registration clinical trials and what they are designed to achieve, and the placebo effect. Now, a large-scale analysis, published in the rigorously peer-reviewed Archives of General Psychiatry, has strongly validated the experience of patients and clinicians — that antidepressants work. The researchers reviewed a large number of trials of two popular modern atidepressants, fluoxetine (Prozac) and venlafaxine (Effexor) which included 9,182 patients. Extremely robust and clinically relevant improvements were seen, including on measures of both response and remission. In addition, the benefit of antidepressants was seen regardless of the severity of depression, which ranged from mild to severe. Every patient is unique, and despite overall similarities in response rates in clinical trials of antidepressants, a thorough assessment of patient characteristics, including symptoms that might be co-existing with depression, like anxiety or lack of motivation, and the unique features of particular antidepressants, can determine the best option for each individual patient.

Best Regards, Dr. Ranen

Neal G. Ranen, M.D., Psychiatrist Baltimore County