Effective therapies for banishing winter depression
Seasonal affective disorder, or SAD, is very common amongst those with environmental illnesses. By far the most common form experienced is "winter depression" in which sufferers become increasingly depressed as sunlight intensity and daylight hours decrease in the fall/autumn and through the winter months. Those with SAD can experience varying degrees of depression from a vague feeling that something is not quite right, to intense feelings of sadness and despair, and even thoughts of suicide. Along with depression, SAD sufferers may also sleep more in winter, as if they want to hibernate. Feelings of fatigue and lethargy are also prominent.
Obviously symptoms such as these can have a serious impact on an individuals ability to function normally. SAD can be devastating to anyone, but when you already have to deal with environmental illnesses such as chronic fatigue syndrome and fibromyalgia, this can truly feel like the last straw.
Thankfully, there are a number of highly effective ways to reduce symptoms of SAD, or even banish it for good. Some of these are simple and can begin to work immediately, some require more effort or expense. The encouraging thing is that almost everyone can gain some relief from their SAD symptoms using the treatment options below, either alone or in combination.
Get More Natural Light
By far the most effective way to get rapid relief from SAD is to get more exposure to natural sunlight. Not only is this the most effective treatment, it is also easy and, up to a point, completely free!
In simple terms, SAD is a bigger problem the further away from the equator you are as there is less light available in winter. The less sunlight you are exposed to during the winter month, the more likely you are to develop SAD to some degree. This is because sunlight helps to regulate a multitude of hormones and neurotransmitters that control the body clock and have strong effects on mood and behaviour. Two of the main players are melatonin and serotonin. When the sun goes down the pineal gland signals the production of melatonin to increase, which in turn signals the body that it is time to sleep. In the morning when sunlight enters the eye, the pineal gland signals production of melatonin to decrease and that of serotonin to increase. Serotonin wakes us up and keeps us in a good mood, brining emotional stability and allowing us to see the sunny side of life! Sunlight hitting bare skin is also very important. The body requires sunlight on the skin to be able to produce vitamin, which has important mood modulating properties of its own, as well as playing a role in influencing other important chemicals.
The varying levels of sunlight throughout the year affect every living thing, from grass to trees, hibernating hedgehogs to humans. Healthy humans can often adapt to the lower levels of sunlight in winter perfectly happily. SAD sufferers however are especially sensitive to changes in light levels and the winter months can severely upset the normal chemical balance of the body. In SAD sufferers, melatonin levels tend to remain too high during the day, making the sufferer feel sleepy, and serotonin levels remain too low, which results in depression and fatigue.
So, if you are troubled by SAD, the best thing to do right away is maximize the amount of sunlight you are exposed to. There are a number of ways you can do this, some practical for everyone, some not so practical. Here are some of these:
- Wake up with the sun
- Get outside in the sun as much as possible
- Take vacations to the sun during winter
- Make sure your home makes the most of the sunlight
- Relocate further south (further north if you live in the southern hemisphere)
Wake up with the sun
It is essential to make the most of the daylight hours, which means waking up at dawn even if you don't have to. If you have been waking up late every day and only getting a few hours of daylight, you will be amazed how much your mood will improve simply by waking up earlier every day. The key here is EVERY day (or almost every day at least). The more consecutive days you wake up early with the sun, the better you will feel. If you have environmental illness and usually sleep well into the morning it can be hard to make this change at first. After a few days of extra sunlight however, you will probably be pleasantly surprised how much better you feel and the effort of waking up earlier won't seem so bad. Of course you still need to get a good night's sleep, so make sure you get to bed earlier at night too!
Get outside in the sun as much as possible
In terms of evolution, it is only very recently that humans have been couped up indoors all day with little or no exposure to the sun. The human body requires sunlight to be truly healthy. To produce vitamin D in optimal amounts the skin must be exposed to the sun every day. Likewise, sunlight needs to enter the eye and reach the pineal gland for it to properly regulate the all important body clock and numerous chemical messengers. Getting outside in the sunlight every day, or even every other day, can really improve the symptoms od SAD considerably. It is best to do this when the sun is highest in the sky around 11am-1pm. It doesn't have to be for too long either, you may want to take your dog for a longer walk or choose to walk to the store instead of driving. Any effort to get yourself out in the sunlight, particularly between 11am-1pm could make a big difference to the way you feel.
Take vacations to the sun during winter
If your finances allow, taking a vacation to the sun in midwinter, can give you a welcome break from SAD symptoms. You should feel better for a while after your return home too, and by this time the days should be starting to get longer again. If you usually take an annual vacation during the summertime, it may be worth considering switching to the winter if you have problems with SAD.
Make sure your home makes the most of the available sunlight
The amount of light in your living space obviously has a lot to do with the direction in which the building faces. If you are in a position to move to a more well lit property, then that may be something worth considering. This is probably not an option for the majority of people however, but there are still things you can do to make the most of the available light. For instance, make sure you keep blinds and curtains open throughout the day. You may wish to change large thick curtains for blinds that don't obscure the windows so much. Also consider factors outside your home. Are there big trees or bushes outside your home stopping sunlight from reaching you? It's certainly worth trimming these or having them cut down if it is a considerable issue.
Relocate further south (further north if you live in the southern hemisphere)
If all else fails and the opportunity is there, then moving closer to the equator should reduce the severity of your SAD permanently. Obviously you will want to try all of the above methods first to make sure that extra light really does help you considerably.
Bright Light Therapy
The first line of treatment recommended by most doctors for seasonal affective disorder is bright light therapy. This involves the patient sitting in front of a "light box", an artificial source of bright light, for a certain period every day. This can range from 30 minutes to several hours, either in the morning or afternoon, or sometimes both. Bright light therapy with light boxes has been shown in many studies over the years to be a very effective treatment for most SAD sufferers, providing at least a modest improvement in symptoms in nearly everyone. As such, bright light therapy can be a very important treatment for the SAD patient, especially since it is not always possible to get outside in natural sunlight every day during winter due to poor weather.
Light boxes have a "lux" rating, which is simply an indication of the intensity of the light they produce. Most studies into light therapy for the treatment of seasonal affective disorder have used light boxes with a rating of 10,000 lux and these are widely available to the public. Light boxes with lower lux ratings are also available but treatment periods will need to be longer to produce the same positive effects as a shorter period in front of a 10,000 lux unit. The initial cost of a light box can seem high but remember that it is a one time expense, besides changing the bulbs, which in most cases will last many years. Most of the alternatives to bright light therapy such as medications and/or natural remedies require repeated purchasing, so in the long run, bright light therapy is actually an economical option. Of course, it is a very good idea to try a light box for a period of a few weeks to a month before you buy one, to make sure it benefits you. Many retailers understand this and offer a trial period, usually 30 days, in which you can return a light box no questions asked, if you find it doesn't help your SAD symptoms. There are also companies and doctors from whom you can rent a light box to try it out.
With regards to research into bright light therapy for the treatment of SAD, one comprehensive study conducted at the Department of Psychiatry, Columbia University, New York, in 1999, tested the effects of 30 minutes exposure to 10,000 lux light on 83 patients diagnosed with the "winter depression" form of SAD1. The therapy was given either morning OR evening for 10-14 days. This allowed the researchers to note any differences in response depending on the time of day the bright light therapy was given. Each patient completed a comprehensive questionnaire rating the severity of 88 physical and subjective symptoms, both before and after the treatment period. The study results mirrored those of earlier, less comprehensive studies, in finding that by far the most predominant effect of bright light therapy was a reduction in symptoms. The study did however note a number of minor side-effects including jumpiness/jitteriness (8.8%), headache (8.4%), and nausea (15.9%). These seem to be the most common side-effects experienced, not just by patients in this study, but by people using light boxes to treat SAD in general. These symptoms are usually very mild and can often be eliminated by adjusting the period of light exposure. An important finding to come out of this study was that jumpiness/jitteriness was more of a problem when the light therapy was given in the morning. So if this is a problem for you, it is definitely worth trying the therapy later in the day. Interestingly the study also found that the bright light therapy also greatly improved non-depressive symptoms including poor vision and skin rash/itch/irritation. This led the researchers to suggest that light therapy may be an effective treatment for many other conditions other than SAD.
Another kind of therapy that uses light is known as dawn simulation. Unlike bright light therapy however, dawn simulation uses much lower light intensities, in the range of 100-1700 lux, compared to 2500-10000lux for bright light therapy.
Dawn simulation uses special lamp usually placed by the side of your bed. The device is very similar to an alarm clock but uses light instead of sound to wake you up. The lamp is usually set to gradually increase in brightness for a period of 30 minutes to 2 hours before the time you wish to wake up and get out of bed. This system is designed to simulate a natural dawn in the summertime, when you would get the same effect from sunlight coming through your window. The dawn simulator lamp effectively fools your body into producing the same responses it would during the sunny summer months, even in the heart of winter when skies are overcast and there is very little light in the morning.
Dawn simulation effectively restores the body's circadian rhythms, normalizing levels of the all important melatonin and serotonin and ensuring their respective production occurs at the correct times during the day and night.
In a 2002 study, 50 SAD patients not receiving other treatment for their condition, were treated with either 250lux dawn simulation or a placebo lamp for 1 week. The results showed that dawn simulation significantly decreased the difficulty patients experienced waking up and also their level of sleepiness after awakening2. In 2001, the same research team had compared dawn simulation to bright light therapy and placebo, and found dawn simulation to be the most effective at treating SAD3. Interestingly, the researchers made special note of the fact that more sunshine hours in the weeks preceding each evaluation translated into decreased SAD symptoms. This underlines the importance of getting as much natural light as possible, even if a therapy such as dawn simulation is also helpful to some degree. Finally, a study published in 2006 compared the effectiveness of bright light therapy, dawn simulation, dawn pulse, and negative air ionization in both high and low density forms. The study involved 99 SAD patients who were randomly assigned to receive one of the 5 treatments for a period of 3 weeks. The study found dawn simulation was second in effectiveness only to bright light therapy13.
So, from the relatively few studies that have assessed the effectiveness of dawn simulation, it seems to be comparable to bright light therapy and other effective SAD treatments. Dawn simulation does have advantages over bright light therapy in that the lamps are much cheaper and the therapy requires much less effort on the part of the patient (something that shouldn't be taken lightly in a condition such as SAD).
Our bodies usually produce large amounts of vitamin D3 (cholecalciferol), the most bioactive form, when our skin is exposed to sunlight. Obviously in winter, especially in very northerly or southerly latitudes, our exposure to sunlight is very low as we wrap up in thick clothing and hide away indoors where it's warm. As a result our vitamin D production can drop to almost zero and deficiencies become a problem. Vitamin D deficiency has been implicated in a number of serious illnesses, from osteoporosis to cancer and high blood pressure. Vitamin D deficiency can also have a marked effect on mood, with studies showing that people with low vitamin D levels are far more likely to suffer from depression than those with higher levels4,5.
The fat soluble vitamin D is confusingly named, as it is actually a powerful hormone. It has a major role in the conversion of the amino acids to neurotransmitters , tryptophan to serotonin, and tyrosine to dopamine and norepinephrine. It performs this role within the brain, and in the adrenal glands. Much of this is performed through vitamin D's close relationship with calcium, as calcium literally controls the communication between neurons (brain cells). This relationship with calcium is also why vitamin D is important for bone health. The neurotransmitters serotonin, dopamine, and norepinephrine have a huge impact on mood, so if vitamin D is deficient and they are not produced in sufficient amounts, the result is depression. Since sun exposure and vitamin D production are much lower in the winter, most vitamin D deficiency related depression is in the form of SAD.
Luckily for those who can't get the extra sun their body needs to produce enough vitamin D on its own, it has been found that vitamin D3 (cholecalciferol) supplements can be very effective at treating SAD. Although the number of studies published on the subject is quite low, all have produced favourable results. An important and widely cited study conducted at The Department of Medicine, Union Memorial Hospital, Baltimore, compared the effects of a single 100,000IU vitamin D injection to 1 months bright light therapy on the condition of 15 SAD patients6. Eight patients were given vitamin D and seven were given light therapy. Before and after treatment each patient was evaluated using the Hamilton Depression scale, the SIGH-SAD, and the SAD-8 depression scale. The results showed that every patient given vitamin D improved on all 3 depression scales, whereas the patients given bright light therapy failed to significantly improve on any. The study also found that both treatments elevated vitamin D status after 30 days but that the vitamin D injection raised levels twice as much as did bright light therapy. The amount each patients vitamin D levels had risen also correlated strongly with the reduction in symptom severity achieved. So in this study at least, vitamin D was actually a lot more effective than bright light therapy for the treatment of SAD. It should be noted however that 15 participants is a low number to get very accurate results and that bright light therapy has proven effective in many other studies.
Other studies have used oral vitamin D3 supplementation, also with positive results. One such study gave SAD patients either 400iu of vitamin D3, 800iu of vitamin D3, or a placebo, for 5 days during late winter under double blind conditions (patients or researchers didn't know who got which treatment until results were in). The study found that even after such a short treatment period the patients given the vitamin D, in either dose, significantly improved7. Higher doses have been used in other studies, typically 4000iu per day. This has been found to be a safe dose with even more positive effects on mood than lower doses8.
Vitamin D3 supplements are widely available from health food stores and are very cheap, making vitamin D3 supplementation a treatment well worth experimenting with if you suffer from SAD.
You may also wish to have your Vitamin D levels checked to make sure you truly have a deficiency. Most doctors who specialize in using vitamin D for SAD suggest blood levels should be above 35ng/ml (many conventional labs can report as low as 16ng/ml as being normal). Currently you will have to have your vitamin D levels checked by your doctor. It is a good idea to be rechecked periodically when taking supplements to make sure both that it is increasing your levels, but also that they are not getting too high.
You can learn more about the blood test here
Melatonin is a hormone whose main function is to induce sleep by traveling through the bloodstream and transmitting the sleep message to other body systems. In healthy individuals the secretion of melatonin peaks in the middle of the night during our deepest sleep. At dawn, sunlight shining into the eye triggers the pineal gland to switch off the production of melatonin, thus removing the desire to sleep.
Researchers have found that this system is disrupted in people with SAD. When SAD patients were compared with healthy controls, it was found that the SAD patients had consistently higher daytime melatonin levels during the winter months9. High daytime melatonin levels would be expected to produce the symptoms of excessive daytime sleepiness and the lack of motivation and desire to hibernate, that is seen in SAD sufferers. Melatonin also has an inverse relationship with both serotonin and vitamin D, so higher than normal melatonin levels during the day in SAD sufferers results in low serotonin and vitamin D levels, and the associated depressed mood.
Luckily, melatonin is also available as a tablet, capsule or liquid (OTC in the US). A recent review of research into melatonin supplementation found that taking melatonin supplements in the evening effectively "phase-shifts" the disrupted circadian rhythms found in SAD sufferers, normalizing melatonin levels throughout the day and reducing symptoms10. Obviously this has a knock on effect so that levels of other important mood regulators such as serotonin and vitamin D also return to normal as well.
In a study conducted in Finland, 58 people with subsyndromal SAD type symptoms were given either 2mg sustained release melatonin or placebo 1-2 hours before the desired bedtime for 3 weeks. The study found that melatonin significantly improved sleep quality and vitality11.
Like vitamin D, melatonin supplements are relatively cheap and widely available from health stores and pharmacies (at least in the US). Dosages generally range from 0.5-5mg and it's best to take the minimum amount that works for you.
Negative Air Ionization
This therapy is a lot less well known than most of the others for the treatment of SAD but has in fact been shown to be as effective as any of the more well known alternatives.
The therapy involves using an air ionizer, a device that gives particles in the air a negative charge. This therapy is based on the fact that the air in summertime generally has far higher concentrations of negative ions than does winter air. There is also evidence to suggest that the concentration of negative ions in the air may have a regulatory effect on serotonin levels in the brain. This led a number of researchers to investigate whether increasing negative ions in SAD patients environments in winter time may alleviate their symptoms.
Drs. Michael Terman and Jiuan Su Terman have had the most experience investigating negative ionization for the treatment of SAD. In 1995 they conducted a study with 25 SAD patients to discover the effects of negative ionization at 2 different concentrations. Under double-blind conditions, one group of patients were treated with a low-density ionizer (producing 10,000 ions per cubic centimeter) and another group with a high-density ionizer (producing 2,700,000 ions per cubic centimeter). The treatments were given for 30 minutes in the early morning, every day for 20 days. Based on patient questionnaires and clinical observations, the high density was found to have helped 58% of patients and the low density 15%. The Terman's concluded that "treatment with a high-density negative ionizer appears to act as a specific antidepressant for patients with seasonal affective disorder". They also noted that the treatment was free from any side effects and could therefore be recommended as an alternative or supplement to light therapy and other more established therapies12.
The Terman's have since followed this study with a number of others involving negative ionization and various light therapies. In a study they published in 2006 they compared the effectiveness of bright light therapy, dawn simulation, dawn pulse, and negative air ionization in both high and low density forms. The study involved 99 SAD patients who were randomly assigned to receive one of the 5 treatments for a period of 3 weeks. The study found the top 3 treatments to be bright light therapy (57.1% of patients improved), dawn simulation (49.5%), and high density negative ionization (47.9%). The researchers conclude that both dawn simulation and high density negative air ionization are effective alternatives to bright light therapy, and are attractive in that they don't require the effort (and to some extent expense) that bright light therapy does13.
Most of the biochemical changes that occur in SAD are the same as those seen in other forms of depression. This means that natural antidepressants that work for major depression for example, will also help many people suffering from SAD. The herbs and nutrients with the most research backing for the treatment of depression include:
St. John's Wort
This herb has a long history of use for depression, particularly in Germany. It is often prescribed there as a first line treatment rather than pharmaceutical alternatives. There is sound scientific basis for this too. In a number of comparative studies involving St. John's Wort and the antidepressant drug Prozac, the herbal remedy was found to be equally as effective as the drug, with both successfully treating around 50% of depressed patients who received them.
Although the exact mechanism by which St. John's Wort works is unknown, it is thought it may work in a similar fashion to older antidepressant drugs called monoamine oxidase inhibitors (MAOI's). These increase levels of all the major mood elevating neurotransmitters by inhibiting their breakdown. The active compound in St. John's Wort is thought to be hypericum
St. John's Wort is widely available from health food stores. The common dosage used in successful medical trials is 300mg taken 3 times per day. The product you choose should contain 0.3% hypericum. On rare occasions St. John's Wort has been known to increase the sensitivity of the skin to sunlight. This should be kept in mind whilst out in the sun.
Omega-3 Fatty Acids
These essential fatty acids have received a lot of attention over the past few years, not only for their role in treating depression, but also heart disease and other serious illnesses.
The Omega-3 fatty acids EPA and DHA especially have been studied extensively as possible treatments for depressive illnesses. The majority of the brain is composed of fat and it is important that the correct fats are present in the right amounts. As a result of our modern diet, our intake of these omega-3 fatty acids tends to be too low, resulting in low levels in the brain. This compromises the function of the brain in many ways including the slowing of nerve transmission and a decrease in important mood enhancing neurotransmitters including serotonin and dopamine.
Studies have found that supplementing omega-3 essential fatty acids (EFA's) can have a profound antidepressant effect. In particular, it has been found that pure EPA is highly effective at treating depression in doses of between 1 and 2 grams per day in divided doses. This is likely due to it improving communication between brain cells and increasing levels of neurotransmitters. Some studies have shown that supplementing omega-3's alone can boost serotonin and dopamine levels by up to 40%.
The direct precursor to serotonin, it is produced from the amino acid tryptophan. Supplements of 5-HTP have been available for a number of years now. It is known that taking these supplements can boost levels of serotonin and effectively treat depression. Tryptophan has also been shown to increase serotonin levels but taking 5-HTP directly may be even more effective, missing out the first step in the production of serotonin entirely. 5-HTP may be particularly effective for SAD which is considered by most to have a major low serotonin component.
5-HTP is relatively cheap to buy. A typical dose is 200-300mg before bedtime. Taken at this time, 5-HTP can also help with sleep problems.
SAMe is the active form of the amino acid methionine. It plays many important roles in the body, mainly through it's action as a "methyl donor". This simply means that it is able to pass methyl groups to other chemicals in the body that require them. A methyl group is a single carbon atom attached to three hydrogen atoms, which has the ability to bond to another atom or molecule. With regards to depressive illness, methyl groups are used extensively in the brain to recycle neurotransmitters. In this way SAMe can raise brain levels of neurotransmitters, particularly dopamine and norepinephrine, and have a powerful antidepressant effect. It has a lesser effect on serotonin however, so it is maybe not the first choice for treatment of SAD.
SAMe is available from all good health food stores but is very expensive due to the difficulty involved in it's manufacture and packaging. Typical doses for depression ar 400-1600mg per day.
As with natural antidepressants, the prescription antidepressant medications used to treat major depression are sometimes prescribed for SAD as well. If you don't mind taking these drugs you may wish to discuss them with your doctor for use on their own or in combination with the other treatment options we've looked at. The most commonly prescribed antidepressant medications used for SAD are the selective serotonin reuptake inhibitors (SSRI's) such as Prozac.
Now that we've discussed the most effective and commonly used treatments for SAD it is worth mentioning using them in combination. As always, it is best to discuss any treatment with your doctor, but all the natural treatments above are considered safe to use in combination. Using say bright light therapy alongside daily vitamin D supplementation may produce more benefit than one of those treatments alone. Again, bright light therapy and melatonin therapy compliment each other and can be highly effective at both restoring a natural sleeping pattern and reducing depressive symptoms.