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What can nurses offer for winter depression?

John M Eagles
MB ChB MPhil MRCPsych
Consultant Psychiatrist,
Royal Cornhill Hospital Aberdeen

The influence of the seasons on human wellbeing was recognised by Hippocrates and Aristotle, and over the ensuing centuries some psychiatrists recognised a condition named as winter melancholy. Not until 1984, however, was seasonal affective disorder (SAD) - of which winter depression is the most common presentation - established as a respectable diagnostic entity.(1) Clinical researchers described 29 patients who experienced recurrent seasonal depressions and reported the beneficial effects on 11 patients of bright artificial light. Some doctors remain sceptical of the diagnosis, but scepticism appears to be receding as evidence accrues on the epidemiology and biology of winter depression and response to treatment.
It is an interesting paradigm to think of winter depression as a form of attenuated hibernation, which may have conferred evolutionary advantages upon our cave-dwelling ancestors. The hormone melatonin almost certainly mediates seasonal changes in our sleep-wake cycle, and in SAD, sufferers experience circadian phase delay: that is, they are hypersomnolent in the morning and often livelier in the evening, as in those experiencing jet lag after flying west to east. This phase-shift hypothesis in SAD is thought to underlie the effectiveness of morning-light therapy.

Symptoms of SAD
The hallmark of winter depression is annual episodes that start in the autumn and winter and remit in the spring. Some clinicians regard complete summer remission as an important diagnostic criterion; certainly, in my experience, people who report normality in the summer (even to the extent of slight overactivity, exuberance and extraversion) tend to respond better to winter treatment. As in nonseasonal depression, sufferers experience low mood (often worse in the morning), anergia, low libido, anxiety, irritability and social withdrawal. The following symptoms, however, tend not to occur in nonseasonal depression but to characterise the presentation of SAD in winter:

  • Hypersomnia.
  • Daytime somnolence, often peaking in the late afternoon.
  • Increased appetite, often for carbohydrates and chocolate.
  • Weight gain.

Epidemiology
Two UK community studies (in Aberdeen and north Wales), both using similarly tight diagnostic criteria, found prevalence rates for SAD in the adult population of 3.5% and 2.4% respectively.(2,3) These figures probably represent the clinically significant end of a spectrum of symptom severity. Most people in the UK will experience to a degree some of the winter symptoms, notably lower mood and energy, increased sleep requirement and dietary changes. For most, no treatment is merited, but at the more clinically severe end of the spectrum it becomes more contentious as to whether the "disorder" should be recognised and "medicalised". The term "subsyndromal SAD" has been coined for a milder version of the full syndrome, on the basis of a putative response to light therapy, but such findings await confirmation.(4)

Presentation
While SAD exists (and can be treated successfully) in children, its prevalence increases significantly at puberty, notably among girls, so that there is quite a marked preponderance of female adult sufferers. This does not endure into old age, probably indicating that aetiology is partly linked to female reproductive hormones.
After screening many patients in primary care, our research group compared SAD sufferers with controls who experienced little or no seasonal change in wellbeing. The SAD patients were heavy users of healthcare services, having more consultations, tests,  prescriptions and specialist referrals.(5) Symptoms were often diverse; in addition to psychiatric presentations, SAD sufferers presented more often with gastrointestinal, urinary and musculoskeletal symptoms, pain and infections and received more analgesics and antibiotics. They had more full-blood counts and more thyroid-function tests. As well as an excess of psychiatric referrals, they saw more physiotherapists and gynaecologists. In short, they presented with and were investigated and treated for a wider variety of somatic complaints.
The diagnosis of SAD had rarely been considered in these patients, probably because of the frequency of somatised presentations, which are known to obscure diagnoses of affective disorders. Along with this "somatising camouflage", however, the typical recurring symptoms of SAD can, one hopes, be elicited; successful diagnosis and treatment is a rewarding enterprise.

Management
For mildly affected people, self-help should be advocated and the most important elements are:

  • Regular exposure to natural daylight.
  • Remaining physically active in the winter.

Regular walks outside combine these elements, while a positive approach to the time-limited nature of the symptoms is helpful. For severely affected people, self-help measures should be coupled with antidepressants and/or light therapy.
Patient preference, including availability and convenience, will often heavily influence the choice between antidepressants and light therapy. Otherwise, it is logical to start with an antidepressant when "nonseasonal" symptoms (eg, weight loss) predominate, and with light therapy when symptoms of hypersomnia and carbohydrate craving are present. Some treatment options are summarised in Box 1.

[[NIP18_box1_71]]

References

  1. Rosenthal NE, Sack DA, Gillin JC, et al. Seasonal affective disorder: a description of the syndrome and preliminary ­findings with light therapy. Arch Gen Psychiatry 1984;41:72-80.
  2. Eagles JM, Wileman SM, Cameron IM, et al. Seasonal affective disorder among primary care attenders and a community sample in Aberdeen. Br J Psychiatry 1999;175;7472-5.
  3. Michalak EE, Wilkinson C, Dowrick C, et al. Seasonal affective disorder: ­prevalence, detection and current treatment in north Wales. Br J Psychiatry 2001;179:1-4.
  4. Kasper S, Rogers SLB, Vancey A, et al. Phototherapy in individuals with and without subsyndromal seasonal disorder. Arch Gen Psychiatry 1989;46:837-44.
  5. Eagles JM, Howie FL, Cameron IM, et al. Use of health care services in seasonal affective disorder.Br J Psychiatry 2002;180:449-54.
  6. Avery DH, Eder DN, Bolte MA, et al. Dawn ­simulation and bright light in the treatment of SAD: a controlled study. Biol Psychiatry 2001;50:205-16.

Resources
SAD Association
PO Box 989
Steyning BN44 3HG
W:www.sada.org.uk