Sleep and Be Well

Mysteries of the slumbering psyche.

A SAD Tale

New research sheds light on winter depression

Aurora Borealis
Aurora Borealis. Seasonal affective disorder is more common closer to the Poles. Photo taken outside my former home in Winnipeg.
Photo taken outside my former home in Winnipeg.
At 7:20 a.m. every year on February 2, thousands of people gather in western Pennsylvania as Punxsutawney Phil leaves his burrow at Gobbler’s Knob, observes the weather conditions, looks for his shadow, and makes his prediction regarding whether there will be an early spring or six more weeks of winter.

For those who live in northern climes where there is little sunlight in the winter, who develop daytime sleepiness, depressive symptoms, food cravings (especially for carbohydrates) and weight gain, spring can’t come soon enough.  They suffer from Seasonal Affective Disorder (SAD), also called winter depression, and its incidence increases the closer one lives to the North and South Poles. Thus we see more SAD in Alaska (almost 10% of the population) than in Florida (less than 2% of the population), with the symptoms lessening as the days grow longer.  

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A Genetic Factor

The common wisdom is that SAD is light-related, and therefore, extending the day with artificial light has been described as a treatment.  However, recent research suggests that light therapy is only part of the story.

While the reduced amount of daylight during the winter plays an important role in SAD, the syndrome cannot be traced to the amount of daylight exposure alone.  Rather, recent research suggests that susceptibility to SAD may be related to variations in genes responsible for the production of a pigment called melanopsin.  Specialized cells (called ganglion cells) in the retina contain the light-sensitive melanopsin pigment and are believed to play a role in resetting our circadian clock as well as setting our mood. That may explain why some northern populations, such as those of Icelandic descent in Iceland and Canada, may be protected from developing SAD.  It has been hypothesized that in patients with SAD, retinal sensitivity to light is decreased and that, together with the reduction in winter light, these factors act synergistically to trigger winter depression.

The Sleep-Mood-Diet Conundrum

Some researchers have used the phrase “circadian desynchrony” to describe the mismatch between a person’s circadian clock and the world around her.  This desynchrony can have an effect on mood.  Patients with SAD spend more time in bed awake, require more time to fall asleep, and more often experience poor sleep quality.  The combination of these factors can impact several hormone systems, including those involved in appetite control and metabolism.  Reduced sleep time changes the levels of hormones that control appetite (leptin and ghrelin) and may negatively impact how the cells in the body respond to the hormone insulin.  As if adding insult to injury, the lack of a good night’s sleep can also make you grumpy and lead to weight gain.

New Therapies on the Horizon

Starting in October and throughout the winter season (for those of us in the Northern Hemisphere), a 30-minute exposure first thing every morning to bright light — whether natural sunlight or a “light box” — can be effective in treating or preventing SAD.  Since the circadian system is especially sensitive to blue light, researchers are studying the effectiveness of a lower intensity and duration of exposure to blue enriched light.  However, the jury is still out on whether these light treatments have negative effects on vision.

Since SAD is a form of depression, its mood effects can be treated with antidepressants. Interestingly, there is little evidence that the hormone melatonin itself has a positive effect on depression or SAD.  However, agomelatine, a new antidepressant compound available in some countries, may be effective.  This medication stimulates melatonin receptors in the brain and antagonizes serotonin receptors.

While Seasonal Affective Disorder is not usually life-threatening, it can lead some patients to suicidal ideation.  Patients with significant symptoms will benefit from treatment and must seek professional help.  It has been reported from a research group in Vancouver, Canada, that light therapy may lessen suicidal thoughts in patients with SAD.

Seasonal Affective Disorder, like all mental illness, is real, and researchers continue to study how best to address its symptoms.  Fortunately, its effects wane as the days grow longer.  Here’s hoping that because Punxsutawney Phil didn't see his shadow on February 2, that we will have an early spring!

 

References

In The iGuide to Sleep,” an Apple iBook that I wrote for the iPad, there is section about Seasonal Affective Disorder that includes a virtual lightbox.  This virtual lightbox has not been clinically tested and is provided only to show what blue enriched light looks like on a tablet device.  People suffering from SAD should not treat themselves, but should seek treatment from a clinician familiar with all aspects of treating SAD. 

Michael and Jiuan Terman have written an excellent chapter on the specifics of light therapy (Chapter 149: Light Therapy), in Kryger M, Roth T, Dement WC ,Eds., Principles and Practice of Sleep Medicine (Elsevier, 2011).

 

Readings Cited

Coogan AN, Thome J. Chronotherapeutics and psychiatry: setting the clock to relieve the symptoms. World J Biol Psychiatry. 2011 Sep;12 Suppl 1:40-3.

Gordijn MC, 't Mannetje D, Meesters Y. The effects of blue-enriched light treatment compared to standard light treatment in Seasonal Affective Disorder. J Affect Disord. 2012 Jan;136(1-2):72-80.

Lam RW, Tam EM, Shiah IS, Yatham LN, Zis AP. Effects of light therapy on suicidal ideation in patients with winter depression. J Clin Psychiatry. 2000 Jan;61(1):30-2.

Laposky AD, Bass J, Kohsaka A, Turek FW. Sleep and circadian rhythms: key components in the regulation of energy metabolism. FEBS Lett. 2008 Jan 9;582(1):142-51.

Roecklein KA, Wong PM, Miller MA, Donofry SD, Kamarck ML, Brainard GC.  Melanopsin, photosensitive ganglion cells, and seasonal affective disorder. Neurosci Biobehav Rev. 2012 Dec 31;37(3):229-239.

Srinivasan V, Zakaria R, Othman Z, Lauterbach EC, Acuña-Castroviejo D. Agomelatine in depressive disorders: its novel mechanisms of action. J Neuropsychiatry Clin Neurosci. 2012 Summer;24(3):290-308.

Stephenson KM, Schroder CM, Bertschy G, Bourgin P. Complex interaction of circadian and non-circadian effects of light on mood: shedding new light on an old story. Sleep Med Rev. 2012 Oct;16(5):445-54.

Wielgus AR, Roberts JE. Retinal photodamage by endogenous and xenobiotic agents. Photochem Photobiol. 2012 Nov-Dec;88(6):1320-45.

Meir H. Kryger, M.D., is a professor of Medicine at the Yale School of Medicine and editor of Principles and Practice of Sleep Medicine, 5th Edition, and Kryger’s Sleep Medicine Review.

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