Fall is Here, Why Do I Feel So SAD?: What is Seasonal Affective Disorder and How Can it Be Treated?

The best time of the year can sometimes bring out the worst of our feelings. The transition into the fall season has many things we can look forward to such as the holidays, fall festivities like pumpkin and apple picking and much more. However, along with the positives of fall come the negatives: As the seasons change, the weather becomes colder and the days become shorter. These factors can lead to some individuals developing seasonal affective disorder (SAD), also known as seasonal depression.

Seasonal affective disorder is a specific type of depression that is linked to the changes of the seasons (Mayo Clinic, 2021). For most people diagnosed with SAD, the symptoms begin during the fall and usually last throughout the winter months, resolving in the spring. Another less common form of SAD is developed during the spring and summer months and settles down during the fall. Some of the symptoms of fall and winter SAD include hypersomnia, or oversleeping, overeating (with a craving for carbohydrates), weight gain, and social withdrawal when one feels like “hibernating” (NIMH). The causes of these symptoms, and SAD in general, are not yet fully understood by professionals. Although, research suggests that individuals with seasonal depression may have reduced activity of the neurotransmitter serotonin. Serotonin's role in our brains is to regulate our moods. When an individual has normal levels of serotonin, they tend to feel happier and more emotionally stable. Therefore, if an individual is experiencing low levels of serotonin, they are more inclined to feel depressed (Cleveland Clinic). It has also been suggested that sunlight plays a part in controlling the levels of molecules that help regulate serotonin levels. In people with SAD, the maintenance of serotonin levels does not function properly. As a result, there is a decrease in serotonin for them during the colder and darker months of fall and winter (NIMH). The drastic decrease in sunlight also affects vitamin D production in the body. Vitamin D is believed to be important in boosting serotonin levels. Thus, lower levels of vitamin D will contribute to lower levels of serotonin activity in the brain, making us feel more melancholy than in other times of the year that have more hours of sunlight (NIMH). 

While the symptoms of SAD may lead one to feel hopeless or overwhelmed, there are different treatment methods that can be used to help relieve them. Since SAD is a type of depression, some of the treatments are the same as that of Major depressive disorder (MDD). One of these treatments is psychotherapy, specifically cognitive behavioral therapy (CBT).  CBT is a form of talk therapy in which an individual works with a licensed counselor or other mental health professional to talk through and learn how to cope with difficult thoughts and feelings. CBT for patients with SAD may focus primarily on shifting the negative thoughts they have surrounding the winter season to a more positive light. This can be achieved through a process called behavioral activation. Behavioral activation helps individuals to identify and create a schedule of enjoyable indoor and/or outdoor winter activities that they can engage in to fight the loss of interest brought on by this time of year (NIMH). Another kind of treatment for SAD, which is also used for MDD, is antidepressant medication. Since serotonin dysregulation is common in people with SAD, selective serotonin reuptake inhibitors (SSRIs) may be prescribed to increase serotonin levels and thereby regulate mood (NIMH).

A treatment that is specifically geared towards healing SAD would be light therapy, also known as bright light therapy (BLT). Light therapy, which has been around since the 1980s, works to expose individuals with SAD to artificial light that mimics natural outdoor light. BLT is administered in the form of light boxes with suggested exposure time of 30-45 minutes a day, preferably in the morning. Psychologist Adam Borland recommends using the light box as early in the day as possible. Dr. Borland specifies that one should not be looking directly at it,  but rather using it as a nearby passive light source in their indoor space (Cleveland Clinic, 2021). Another SAD-specific form of treatment is taking vitamin D supplements. As mentioned earlier, many individuals with SAD may experience some sort of vitamin D deficiency due to the lack of sunlight during the fall and winter months. Therefore, taking these vitamin D tablets may help improve symptoms for some (NIMH).

Just because SAD season is upon us, doesn’t mean that those of us who struggle with it should spend all of the colder months feeling sad. All of the treatments mentioned above have been found to be effective in relieving the symptoms of SAD. Of course, like any other condition, everyone is different and what works best for one person might not be what works best for another. Regardless, finding a form of SAD treatment that benefits you is a great way to enjoy the fall and winter season for all of its unique joys and festivities!

References

Cleveland Clinic. (2021, December 2). How light therapy helps SAD. Cleveland Clinic. Retrieved October 5, 2022, from https://health.clevelandclinic.org/light-therapy/ 

Mayo Foundation for Medical Education and Research. (2021, December 14). Seasonal affective disorder (SAD). Mayo Clinic. Retrieved October 5, 2022, from https://www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/symptoms-causes/syc-20364651 

Photograph: https://www.science.org/do/10.1126/science.caredit.aax2505/full/WL_LightH.jpg

Serotonin: What is it, Function & Levels. Cleveland Clinic. (n.d.). Retrieved October 12, 2022, from https://my.clevelandclinic.org/health/articles/22572-serotonin#:~:text=Mood%3A%20Serotonin%20in%20your%20brain,serotonin%20are%20associated%20with%20depression. 

U.S. Department of Health and Human Services. (n.d.). Seasonal affective disorder. National Institute of Mental Health. Retrieved October 5, 2022, from https://www.nimh.nih.gov/health/publications/seasonal-affective-disorder 

Caring for Our Caregivers: Physician Suicide Awareness and Prevention

The conclusion of September brings the end to National Suicide Awareness month, a topic often shunned by public discussion. Awareness regarding this issue should not be limited to just one month, rather year-round conversations are necessary to examine systemic issues and barriers regarding suicide prevention with additional emphasis on high-risk groups. Physicians are one such high-risk group who on average face a higher death-by-suicide rate than other professions, with studies estimating the suicide of 300-400 practicing physicians yearly (Yaghmour et al., 2017, p. 976). It is estimated that “The suicide rate among male physicians is 1.41 times higher than the general male population. And among female physicians, the relative risk is…2.27 times greater than the general female population” (American Foundation for Suicide Prevention, 2022). A fundamental problem exists that perpetuates the crisis seen in medical professionals. 

Not often viewed as the byproduct of an individual event, suicide is commonly the aggregated result of multiple risk factors, with the highest occurrence being mismanaged mental health conditions (American Foundation for Suicide Prevention, 2022). Following the completion of medical school, physicians enter a formative period of residency training for three to seven years to become specialized in their respective fields. Residency training is labor intensive and highly demanding of a physician's time, as individuals may work between 60-80 hours per week depending on their specialty and rotation by standardized working conditions. In 2003, The Accreditation Council for Graduate Medical Education (ACGME) imposed an 80-hour weekly work limit, averaged over four weeks, and 24-hour shift limit guidelines for residents (Accreditation Council for Graduate Medical Education, 2004). Though these regulations were created to combat overwork and sleep deprivation for residents, studies have shown it is a common occurrence to underreport or falsify one’s hours worked to comply with ACGME. Through an anonymous survey completed by 6202 residents at ACGME-accredited medical programs, “Nearly half of residents (42.9%) responded that they falsely reported their duty hours at some time, including 18.6% who reported falsely at least once or twice per month” (Drolet et al., 2013). Although legal limitations are established for resident working conditions, physician training generally applauds a visible dedication and commitment to maturing in one’s field. This may encourage residents to stay longer to observe more patients, take on more cases, and commit to more educational or academic tasks at home or in the hospital (on their own time). Thus, to fit national compliance, trainees might be more flexible in logging false hours. Long hours translate to fewer hours for oneself, whether it be doing leisure activities or spending time with loved ones.  

Amongst long hours and competitive, high-stress training environments, “... trainees often learn to ignore signs and symptoms of burnout, depression, and suicidality” (Kalmoe et al., 2019). A meta-analytic review of multiple studies examining suicide amongst physicians and healthcare workers found “... between 20.9% and 43.2% of trainees screened positive for depression or depressive symptoms during residency” (Mata et al., 2015). It is important to note that a significant increase in the onset of depressive symptoms lies at the start of residency, which supports the finding that training experience across all specialties is commonly distressing to the individual’s mental health  (Mata et al., 2015). In a study cohort of 740 first-year U.S. residents across 13 institutions and multiple specialties, it was examined that suicidal ideation escalated by 370% over the first several months of their training year (Guille et al., 2015). 

While physician training applauds fortitude and passivity from its residents, it is no doubt that the profession demands for its trainees to forgo themselves to be more devoted to their training. Though physicians routinely check for their patient's mental health concerns, medical culture routinely stigmatizes mental health treatment and support for its own. Lacking an adequate support network can further amplify the dehumanizing experience faced by medical trainees leading them to isolation in combating their mental health issues. Similar to the barriers faced by many others, resident physicians may also come across financial and social barriers in seeking mental health treatment. With medical educational debt having an average of $200,000-$300,000 and resident salaries being around $50,000-$60,000, residents may struggle to obtain affordable care or therapy combined with their other living expenses and continuing medical education. With finances not being a concern, even finding adequate time to schedule appointments may be difficult with the long shifts and on-call hours. 

While it is advised for physicians, particularly residents, to address their mental health conditions through treatment, it is vital to recognize this issue not as a personal conflict, but as a systemic crisis. Individual actions may fall short of the larger issue at hand, which is a large burden placed on physicians during their training to constantly be more and do more. It is crucial for medical training to become humanized to combat depressive symptoms faced by physicians and remind them they are not alone. 

References

Accreditation Council for Graduate Medical Education. (2004). The ACGME’s Approach to Limit Resident Duty Hours 12 Months After Implementation: A Summary of Achievements. ACGME Home. https://www.acgme.org/globalassets/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf

American Foundation for Suicide Prevention. (2022). Facts about Mental Health and Suicide Among Physicians. https://www.datocms-assets.com/12810/1578319045-physician-mental-health-suicide-one-pager.pdf

Drolet, B. C., Schwede, M., Bishop, K. D., & Fischer, S. A. (2013). Compliance and falsification of duty hours: Reports from residents and program directors. Journal of Graduate Medical Education, 5(3), 368-373. https://doi.org/10.4300/jgme-d-12-00375.1

Guille, C., Zhao, Z., Krystal, J., Nichols, B., Brady, K., & Sen, S. (2015). Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns: A Randomized Clinical Trial. JAMA psychiatry, 72(12), 1192–1198. https://doi.org/10.1001/jamapsychiatry.2015.1880

Kalmoe, M. C., Chapman, M. B., Gold, J. A., & Giedinghagen, A. M. (2019). Physician Suicide: A Call to Action. Missouri medicine, 116(3), 211–216.

Mata, D. A., Ramos, M. A., Bansal, N., Khan, R., Guille, C., Di Angelantonio, E., & Sen, S. (2015). Prevalence of depression and depressive symptoms among resident physicians. JAMA, 314(22), 2373. https://doi.org/10.1001/jama.2015.15845

Yaghmour, N. A., Brigham, T. P., Richter, T., Miller, R. S., Philibert, I., Baldwin, D. C., & Nasca, T. J. (2017). Causes of death of residents in ACGME-accredited programs 2000 through 2014. Academic Medicine, 92(7), 976-983. https://doi.org/10.1097/acm.0000000000001736