SAD interview

Interview with Rosenthal

Member question:
Are there any prescription medications you have used successfully for SAD that are better than others?

Rosenthal:
Many different antidepressants have been used for the treatment of SAD with some success, but so far, no study has actually tested on antidepressant against another. So at this time, nobody can answer your question with confidence.

In one interesting new set of studies, the antidepressant Wellbutrin-XL was used to try and prevent SAD before it even began, and was successful in preventing the development of SAD in some people.

Member question:
You mean people who had it the year before?

Rosenthal:
Yes. People with a history of SAD in previous winters were entered into the study in the autumn before the development of their winter symptoms, and were given the antidepressant or placebo at that time. There were fewer relapses of winter depression among those that received the antidepressant.

Member question:
And they didn't need light either?

Rosenthal:
In this particular study, there was no light used. So some people can prevent their winter depression by starting Wellbutrin-XL early in the season.

Member questionL:
What is the success rate of light therapy?

Rosenthal:
It really depends on how you define success rate. About 80% of people with SAD get some benefit from the use of light therapy. However, a smaller proportion have their symptoms completely cured, maybe only 40% to 50%. For that reason, many people use more than one kind of treatment and combine light therapy with other forms of treatment in order to obtain complete reversal of symptoms.

Member question:
I cannot afford a vacation down south. What is the best, cheapest lamp to buy for SAD? Or, better yet, is there a special bulb I can screw into my normal lamp?

Rosenthal:
That's a great question. Many times people ask me if they can screw different kinds of bulbs into their lamps. Unfortunately, that rarely solves the problem. The reason is that you need a certain amount of light, a large amount, concentrated in one place, and that's what special light fixtures do; they pack a lot of light into one place.

As far as the best deal is concerned, I recommend that you shop around. You can find a link on my web site, which is www.normanrosenthal.com, to a variety of reputable manufacturers of special SAD lights. You need to be careful, though, because often the smallest and cheapest ones also give off the least total amount of light and are, therefore, not as effective as the larger more expensive models.

One good tip for you to remember is that many of these companies have a 30-day money back guarantee on their products, no questions asked. Check this out before ordering from any of the companies, because what this essentially allows you to do is try out the light and see if it works before settling on your investment, once and for all.

Member question:
How long should you try it before you should see a difference?

Rosenthal:
Most people see a difference within one to two weeks. There are several things to consider in order to get the best effect of light. For a complete trouble-shooting manual, you may want to look at my book, 'Winter Blues: Seasonal Affective Disorder: What It Is and How to Overcome It'. But here are some of the most important things to keep in mind:

• First, mornings seem to be the best time for light therapy. The earlier the better.
• Second, your eyes have to be open and you have to be facing the light in order to benefit, though you do not need to stare at it.
• Finally, be sure there is enough light. And here's where those teeny weeny light boxes may be less effective than the larger ones.

Member question:
Are light visors any good? I'm considering a 2,500 lux one.

Rosenthal:
Many people like the light visor and speak well of it. I, in fact, was one of the people who originally helped develop the light visor. But in several clinical studies we haven't been able to show a difference in the effects of visors of different light intensities. So by all means, go ahead and try it. But if it doesn't work, you may still benefit from the light box.

Member question:
Regarding light therapy, how long of time does one need to be in front of the light?

Rosenthal:
The amount of time varies. I recommend people start with 15 to 20 minutes in the morning, but some people can go up to a couple hours a day. That sounds like a lot of light, but if you think about it, you'll be sitting in one place for a certain amount of time anyway, so you may as well have the lights on.

Remember that if you have a light fixture that puts out a lot of light, you don't have to sit at the prescribed 20 inches or so all day long. The light can be beneficial even if it's in the background. Though for some part of the day you should be close up to get the maximum benefit. What is best is to customize the program for each individual, starting slow and building up gradually.

Remember, light therapy, like any other treatment, can have side effects. These include headaches, eye strain, and overactivation. If used at night too late, it can cause insomnia. So people often learn to be their best judge as to how much light they need in order to get the benefit and minimize the side effects.

Member question:
Other than medication and light therapy are there other forms of treatment?

Rosenthal:
There are lots of things you can do for SAD:

• Managing stress is an important consideration. If you know you have depression in the winter, try not to undertake your heaviest workloads at that time.
• Exercise is great and can be combined with light. For example, you can walk outdoors in the morning on a sunny winter day. Or do your stationary bike in front of your light box.
• A positive attitude always helps. Keeping active, staying engaged with the pursuits that you love, and doing things that you enjoy.
• Friends and family can be invaluable at this time, even if you don't feel at your social best. It is good not to isolate yourself.

Ishould hasten to add that for those people where these self-help measures don't work within a few weeks, you should consult your doctor or mental health professional, because SAD can really be quite bad.

Member question:
What are your thoughts on herbal therapy as an alternative to drugs?

Rosenthal:
St. John's Wort has been shown in many studies to counteract depression, and can be quite useful. You should probably avoid using St. John's Wort together with bright light, as the herb may sensitize the tissue in the eyes to the effects of the light. Some patients have complained about painful eyes and eye sensitivity when using St. John's Wort and light together.

As far as the other herbs are concerned, there is not much evidence to support their benefits. One thing to keep in mind is fish oil extracts. Not an herb admittedly, but a supplement, which holds early promise as a potential antidepressant supplement.

Member question:
I take antidepressants daily for major recurring depression and anxiety. During winter months my medications seem to be too weak when I get symptoms of SAD. Do you recommend higher doses for your patients at this time (after talking to my doctor, of course)?

Rosenthal:
Many people require more medication in the winter than in the summer, but some patients can benefit from having light added to their medication, and can get just as good an effect without increasing the side effects of the medication. Your doctor would certainly be the best judge of which way to go on this question.

Member question:
Is it a "you have it or you don't" thing, or are there varying degrees of SAD? I guess I've always gotten a little down and tired during the winter months, but I don't know if it is clinical or not.

Rosenthal:
I'm glad you asked that question. It's definitely not an either/or thing. Seasonality, which is what we call seasonal variation in mood and behavior, exists on a spectrum. At the one end of the spectrum are people with serious cases of SAD; at the other end are those that don't mind the winter at all, and in the middle are a huge number of people who are under the weather to some degree or another.

These estimated 25 million people in the U.S. with the so-called winter blues may never feel bad enough to seek medical attention, but may nevertheless experience a decrease in productivity or quality of life during the winter months. The good news is that these people can benefit from all the same measures that I recommend for those with more extreme symptoms of SAD, and may also find many helpful tips in my book, 'Winter Blues'.

Member question:
Does cold aversion play any role in SAD, or just light? I never want to leave the house when it's cold. It "defeats" me. I find myself longing for warm weather like a drug!

Rosenthal:
Some people dislike the cold and think it contributes to their SAD symptoms. Certainly the cold keeps people indoors and keeps them from getting their quota of light from the sky. So whichever way you slice it, cold contributes. But it is really light rather than warmth that has been shown to help SAD symptoms.

Member question:
I think I'm just the opposite with SAD. Summers here are oppressive and I seem to go into a deep depression that lifts only in the fall/winter/spring. Is that also SAD?

Rosenthal:
There is clearly a group of people who have symptoms just like yours - summer SAD, if you will. Nobody knows exactly what causes it, though we suspect it may be the intense heat or, in some cases, too much light. In any event, summer SAD can be quite severe, and I usually treat it by anticipating it and starting my patients on antidepressant a few months before their summer symptoms normally kick in.

Member question:
Do you believe that cardio exercise is of greater importance in alleviating SAD?

Rosenthal:
I think cardio exercise is useful for SAD, just as it has other benefits, but I'd hesitate to overstate its importance.

Member question:
What guidelines are used in diagnosing SAD?

Rosenthal:
There are of course formal guidelines, but here are some useful tips. Look back over the last several winters and ask yourself, have you had some or all of the following during the winter months:

• Decreased energy
• Increased need for sleep
• Increased appetite
• Craving for sweets and starches
• Weight gain
• Sad, blue feelings
• Difficulty concentrating
• Withdrawal from friends and family
• Trouble in your job or in running your household
• Problems with your relationships

If you answered yes to several of these questions you may surely be a candidate for SAD. To double check on that, you may want to check in with a professional or get further information from my book. My web site, which also contains relevant information on this point, is www.normanrosenthal.com.

Member question:
How do you politely ask someone to seek treatment for this ailment? My dad is like a recluse in the winter months. He will not leave his home for days at a time. If there is rain or snow expected, you can forget seeing him. He is only 64 years old and acts as though he is 90. I have very nicely told him I thought he may have some depression, but he denies it. So, if you can give me some advice, I would greatly appreciate it!

Rosenthal:
Maybe you might consider purchasing him a light box for Christmas, or something that he might like, too, is the so-called dawn simulator. This is a little electronic gizmo that plugs into a bedside lamp and can be programmed to turn that lamp on early in the morning, thereby simulating a summer dawn. The model I like best is called the Sun Up, and it is available through several of the manufacturers listed on my web site.

It is amazing that light of not brighter intensity than a bedside lamp that comes on while a person is still asleep in the morning can be effective, but that shows how sensitive the eyes are in the early morning hours.

Back to your dad, you might couch it simply by saying, "You know, it gets so dark and dreary, I thought this might cheer the place up." Or, help him install and program the light. That's one thought. It doesn't sound like a direct approach might go down that well.

Member question:
How can you differentiate between SAD and clinical depression?

Rosenthal:
SAD is clinical depression. It can be just as bad as depression that occurs at other times of the year. Its hallmark is that it typically occurs in the wintertime. So it's really one and the same thing.

Member question:
You mention several diets in your book. Any new info?

Rosenthal:
Yes. I now feel that the low-carb diets are really the best way to go. We had observed in our research that people with SAD are energized by carbohydrate-rich snacks, which normally sedate other folks. That led me, in my early days, to encourage people to snack regularly on these foods. Unfortunately, it was not a winning strategy. The carb-rich foods have a backlash. People feel tired after the initial activation, and of course there is the inevitable and unwelcome weight gain.

Take a look at the very popular protein diets, and pick the one you like the best. I am currently developing a new one, but basically a protein-based diet is what I recommend. In fact, that's what I eat myself because, as I mention in my book, I have a certain amount of SAD myself.

Member question:
The Zone is a good one then?

Rosenthal:
I've never gotten into the Zone, because I've found it to be complicated. If you remove pure sugars in your diet and follow that up by taking out the white starches, bread, pasta, potatoes, and rice, you are 3/4 of the way there. Then it is a matter of figuring out how to prepare enjoyable foods without those very high-carbohydrate substances.

Member question:
Earlier you referred to anticipating the SAD season. Do many people resume medications or take other steps leading up to SAD season?

Rosenthal:
Yes. After many years, people begin to recognize that winter is going to be a difficult time and plan accordingly. Get out your light box, start or increase medications, start an exercise program, get a jumpstart on your diet, or plan that winter vacation early. All of these steps will help gear you up for the winter and make it less unpleasant.

In fact, once you get a hang of this thing, winter can become an enjoyable season. It's hard to believe for a SAD patient, but I look forward to the winter now, as do many of my SAD patients. It's only when you get it figured out that you can enjoy all the benefits winter has to offer. No mosquitoes, no intense heat, the beauty of the landscape, the joy of the holidays, the quiet, the unexpected splashes of color like holly or a cardinal on a bush, or a decorative cabbage. All of these are so much appreciated when the rest of the landscape doesn't compete.

Member question:
How does someone with SAD deal with the "stigma" associated with depression as a mental health problem?

Rosenthal:
I've been amazed at how little stigma SAD seems to involve. Perhaps that's because all of us can understand the changes that come about with the changing seasons; the squirrel hiding its acorns, the reindeer shedding their antlers, and so on. So to think of ourselves as seasonal creatures is not so stigmatizing. I've been surprised at how well accepted light boxes have been for most of my patients who have chosen to bring them in.

Member question:
Can SAD turn into bipolar disorder (or other mental health problems)?

Rosenthal:
Some people with SAD are also bipolar. They become depressed in the winter, and may become manic in the spring and summer. So bipolar and SAD can sometimes go together. Most people with SAD, however, do not become manic.

Moderator:
Do you have any final words for us, Dr. Rosenthal?

Rosenthal:
Thank you for having me on your web site. I can't resist mentioning that people who want more information should look at my book. It sums up 20 years of my experience, sufferer, and clinician, and I am now working on a third revision. Also you may look at my web site, www.normanrosenthal.com.