is a psychiatrist and Regional Medical Director for 

Anoopinder Singh, MBBS, MD, FAPA

There is a reason why so many holidays occur during the fall and winter months. For many, these light-filled festivities serve as a symbol of hope, something to look forward to when darkening days threaten to bring a bout of seasonal depression.

With time changes, shorter days, and inclement weather driving people indoors, seasonal depression affects about 5% of adults annually and can last up to 40% of the year.

 Interestingly, it is 4 times more common in women than men.

 (SAD), this recurrent major depressive disorder has a pattern of seasonal emergence and remission.

SAD is thought to be mainly caused by a lack of sunlight. More than 50% of the human population lives in the northern temperate zone between the Tropic of Cancer and the artic region to the north. As a result, SAD tends to peak from December through February, often coinciding with the time of the year when shorter days means 

Although the intention of the holidays is to bring us closer to friends and family, for many it is also a very stressful time. Taking on too many commitments, interactions with family, travel, and disrupted schedules can heap on the stress and make SAD symptoms even worse.

Part of the challenge with SAD is its seasonality, which can catch people off guard if they are not usually depressed. By teaching patients how to identify and address SAD, clinicians can give patients a valuable gift.

-Spring forward, fall back. Each year, 1.6 billion people change the time on their clocks to chase the sun during fall and winter months.

-Benjamin Franklin is widely credited with inspiring daylight saving time when he mused, “Oblige a man to rise at four in the morning, and it is probable that he will go willingly to bed at eight in the evening.”

-William Willet, a builder walking the streets of London, took this one step further in 1907 when he wrote “The Waste of Daylight,” a manifesto on how no one was taking advantage of the early morning sun.

-It was not until World Wars I and II when the need to conserve coal and energy spurred the United States and other countries to adopt light-saving measures. Because it was met with great resistance, an important compromise was reached. Clocks would be turned ahead 1 hour in the spring to give people ample opportunity to 

. In the autumn, daylight saving time would end as clocks fell back 1 hour. 

-While the concept of daylight saving seems to have allowed the optimization of industrial needs, changing clocks in the fall can take a toll on your mental health and may exacerbate mental health conditions. One study reviewed 185,419 hospital contacts following the transition to standard time. It found there was an 11% increase in the rate of 

, including the sleep-wake cycle. It can take some people weeks to get back to healthy sleep patterns. For most Americans, a 9am-to-5pm work schedule is standard, which means it is already dark when the workday is through. This can contribute to decreased sunlight exposure and an increase in sedentary lifestyles.

-To adjust to these time changes, health professionals suggest going to bed incrementally earlier in the weeks leading up to the time change. Sticking to a schedule, avoiding naps, and limiting 

 and alcohol can help smooth out this transition.

SAD was first identified in 1984 by Norman Rosenthal, MD, along with other colleagues. Upon moving from his home of South Africa to the United States, Rosenthal noticed he felt less productive and more lethargic during the winter months. Subsequent research noted that the further people lived from the equator, the higher the rates of SAD. In Florida, for example, only 1.5% of people studied experienced SAD, while it affected close to 10% in New Hampshire.

Symptoms of SAD most commonly include a persistently low mood and a lack (or perceived lack) of energy. People experiencing seasonal depression may feel more irritable than usual, cry easily or frequently, experience lethargy or tiredness, tend to be socially withdrawn or disengaged, and may experience difficulties concentrating. Those affected also tend to sleep more than usual, experience cravings for sugars and carbohydrates, report being less active, and 

Winter depression is the most common form of SAD, with symptoms emerging in the fall and persisting through the winter months. Its milder form is known as “

.” Less common is summer depression, which can occur in the spring and summer months. Symptoms during this time can include insomnia, loss of appetite and weight loss, and increased psychomotor activity, often resulting in agitation, restlessness, or anxiety.

In either form, cases can become severe and cause significant impairment of function. Like all types of depressive disorders, 

Lack of sunlight is the main culprit of SAD, but there are other causes. A series of cloudy days, spending time mostly indoors, and adjusting to the hiccup of time changes are just some of the situations that can cause SAD to proliferate.

The exact cause of SAD has not been confirmed, but scientific research indicates several causal factors.

Low serotonin activity in the brain is thought to be a cause of SAD. Low sunlight leads to higher levels of the serotonin transporter protein, which can lead to a decrease in serotonin activity in the brain. In the summer months, sunlight naturally keeps these protein levels low.

Lack of sunlight can also spur an overproduction of melatonin, a hormone created by the pineal gland that regulates the sleep-wake.

Decreased exposure to sunlight can increase melatonin levels, which can cause increased 

These disruptions in serotonin and melatonin levels can throw off a person’s circadian rhythm. People with seasonal depression tend to have greater difficulty adjusting their internal clocks to seasonal changes in day length, and this can affect their sleep, mood, and behavior.

 levels are also affected by light. Vitamin D is believed to affect serotonin levels, and a deficiency is related to clinically significant depressive symptoms.

 More accurately a hormone, Vitamin D is found in certain foods and is also produced by the skin when exposed to sunlight.

People living away from the equator in far northern and southern latitudes are more at risk for developing SAD. In northern countries, 2% to 9% of people experience SAD, with 15% to 20% experiencing the milder “winter blues.”

 Actual prevalence could be higher due to potential underdiagnosis or underreporting.

SAD is much more common in women, likely related to changes in estrogen levels.5 It also appears more frequently in those with a family history of depression as well as younger people. The onset of 

 Those engaged in shift work, such as health care workers or law enforcement agents, may be at a particularly high risk.

The prevalence of SAD, however, is not without its critics. One 2008 study pointed out that residents of Northern Norway live without the sun for 2 months during the winter, but do not “spontaneously complain” about depression during this time.

 Another study in 2016 examined US data from a cross-sectional survey by the Centers for Disease Control and Prevention.

 Authors said they were unable to find any significant increase in depression rates that could be attributed to a particular season.

 Despite this criticism, identifying cases of SAD is critical for helping people navigate the darkness of the fall and winter months.

SAD is classified in both the ICD-10 and the DSM-5. For a diagnosis to be made, a person must experience depression during a specific time each year for at least 2 years. Once SAD has been diagnosed, there are several promising treatments to help reverse its effects.

 Antidepressants remain a promising and viable treatment option for moderate to severe cases of seasonal depression.

 Although there are concerns about the side effects of these medications, there are several newer options available that have shown promise. Additionally, there are other nonmedication options available, such as neuromodulation, which are effective and may be better tolerated.

 can help significantly reduce the distress and impairment caused by symptoms of SAD. In cases of mild depression, it can be effective by itself or in combination with medications to treat moderate to severe depression. Most of the existing research evidence supports the use of cognitive behavioral therapy.

, including mindfulness-based stress reduction, positive psychotherapy, interpersonal psychotherapy, and brief problem-focused psychotherapies, can also be highly effective. These can empower a person to effectively manage or deflect away from unhelpful thoughts and emotions. It also can help them find successful ways to relax, preserve their ability to function, anticipate and prepare for potential emotional triggers, and see the light at the end of what might seem like a long, dark winter. Reemerging interest in complimentary modalities, including psychedelic psychotherapy, is also inviting greater research and focus.

 seeks to reverse the effects of diminished daylight by exposing a person to an artificial full-spectrum light. Light boxes are easily available, often without prescription, and usually recommended for use during morning hours.

 This is similar in composition to natural sunlight, but with ultraviolet light filtered out. Medical supervision is suggested to ensure the appropriate light intensity, as well as distance, duration, frequency, and timing. This will help avoid any unwanted effects, such as headaches, eyestrain, and, in rare cases, mania and suicidal thoughts. Light therapy is not recommended for people who take certain medications that may cause them to experience unusual sensitivity to light.

 Preliminary clinical studies suggest that people with seasonal depression have insufficient (mild or borderline low levels) or deficient (significantly low levels) vitamin D levels, which are usually caused by a combination of reduced intake through diet, low sunlight exposure due to lifestyle issues or availability during winter/fall months or those engaged in night shift work. Researchers have suggested that daily supplementation with moderate to high dose vitamin D may prevent symptoms of seasonal depression or improve ongoing symptoms.

 Although rare, there is a small risk of adverse effects or toxicity developing with very large doses of vitamin D, so clinicians should work closely with patients and their primary care providers.

 There are many actions people can do on their own to mitigate the effects of SAD. Finding ways to reduce stress, 

, and spending time outside can help shore up energy levels. Eating a diet that is high in protein, along with complex carbohydrates and vegetables, and avoiding fatty foods or simple carbs can also be beneficial. Traveling to sunny destinations has also been associated with helping with mood. 

 Complementary and alternative medicine options have gained popularity in recent decades due to increased awareness, research evidence, and a shift toward a more holistic approach to health care. Nutraceuticals, dietary and herbal supplements, 

 and meditation practices, yoga, acupuncture, and the traditional practices of Ayurvedic, Unani, or Chinese medicine may be useful. 

Although the concrete causes of SAD are still elusive, SAD is a clinical condition that affects millions of people each year.

Several mechanisms may play a role in its emergence, with lack of exposure to light during the fall and winter months being the most notable. Symptoms may vary, but they tend to share similarities with other types of depression.

Timely identification and treatment can be very helpful; lifestyle modulation and adjustments can go a long way. Due to the nature of the condition and risk of being underdiagnosed or undertreated, mental health clinicians should be on the lookout for SAD when assessing referred patients.

1. Traffanstedt MK, Mehta S, LoBello SG. 

Major depression with seasonal variation: is it a valid construct? 

2. Rosenthal NE. What is seasonal affective disorder? Accessed December 22, 2021. 

https://www.normanrosenthal.com/about/research/seasonal-affective-disorder/

Seasonal affective disorder: an overview of assessment and treatment approaches. 

4. Rosen LN, Targum SD, Terman M, et al. Prevalence of seasonal affective disorder at four latitudes. 

Estrogen could control photoperiodic adjustment in seasonal affective disorder. 

6. Seasonal affective disorder. American Psychiatric Association. October 2020. Accessed December 22, 2021. 

https://www.psychiatry.org/patients-families/depression/seasonal-affective-disorder

What is this thing called "SAD"? A critique of the concept of seasonal affective disorder. 

8. Turner VS. Study finds “seasonal affective disorder” doesn’t exist. 

March 15, 2016. Accessed December 22, 2021. 

https://www.scientificamerican.com/article/study-finds-seasonal-affective-disorder-doesn-t-exist/

9. Hansen BT, Sønderskov KM, Hageman I, et al. 

Daylight savings time transitions and the incidence rate of unipolar depressive episodes.

10. Daylight saving time 2021: when does the time change? Almanac. November 4, 2021. Accessed December 22, 2021. 

https://www.almanac.com/content/when-daylight-saving-time

National Center for Complementary and Integrative Health. 6 things to know about complementary health approaches for seasonal affective disorder. Accessed January 10, 2022. 

https://www.nccih.nih.gov/health/tips/things-to-know-about-complementary-health-approaches-for-seasonal-affective-disorder

Articles

Here’s how to help patients see the light when faced with the winter blues.

A Way Out of Seasonal Depression 

The holidays bring cheer and celebration—as well as stress and tension. Although winter festivities are meant to bring friends, family, and colleagues together, they can also be filled with awkward encounters and uncomfortable situations.

For members of the lesbian, gay, bisexual, transgender, queer, and intersex communities (LGBTQI), these experiences include an added layer of stress. Although the holidays are meant to be a time to relax and celebrate, many who identify as LGBTQI must defend themselves against questions, snide comments, and outright hostility. More than half of LGBTQI members hide their personal relationships to avoid controversy and confrontation.

 Others avoid gatherings with family and friends. Faced with discrimination, rejected by family, and not so silently judged, many LGBTQI members end up spending the holidays in loneliness and isolation.

It leaves many in the LGBTQI community struggling to enjoy the holidays in a way that is meaningful and true to them. It also explains why celebrations like Friendsgiving have grown in popularity. Many are choosing to replace traditional holiday family gatherings with more meaningful personal events.

Struggling to cope with awkwardness and rejection goes against the spirit of the holidays, which are meant to offer hope and comfort during winter months. Mental health professionals can give their patients the gift of self-care by talking about these challenges and sharing tips to enjoy the holidays.

Members of the LGBTQI community come from every walk of life. They represent an incredible range of race, ethnicity, religion, socioeconomics, education, and more. What sets them apart is their diverse expression of gender, gender roles, and sexuality.

About 5.6% of adults in the United States identify as LGBTQI, up from 4.5% in 2017. This is a number that has been rising steadily since 2012, when only 3.5% identified as such. It is also a number that includes more diversity in sexual orientation and gender identity. More than half of LGBTQI adults, 54.6%, identify as bisexual. About 24.5% identify as gay, 11.7% as lesbian, and 11.3% as transgender.

In recent decades, the LGBTQI community has experienced a major sociocultural shift in acceptance and awareness along with legal and policy protections. This has lent the community a measure of confidence. But this is a group still struggling for acceptance. For many, coming out as LGBTQI is not easy. It can expose vulnerabilities, drive wedges into relationships, and result in self-stigmatization. These challenges are particularly felt among those who also belong to other minority groups.

The holiday season is already a time of high stress. Planning, entertaining, and gift-giving, coupled with schedule disruptions, overindulgence, and even guilt, can take its toll on anyone. As a result, this is when many abandon healthy routines, increase their use of alcohol and other substances, and compromise their compensatory or coping mechanisms.

At the same time, seasonal depression or “winter blues” can compound the stress and resulting impairments. Plus, the COVID-19 pandemic has exposed everyone to isolation and loneliness. Many have lost loved ones, employment, and relationships. The holidays represent a spectrum of reminders to the highs and lows of one’s life.

Many members of the LBGTQI community are already suffering from limited social and family connections, and all of this can increase feelings of sadness and grief during the holidays. Those who attend family reunions often find it difficult to avoid conflicts and are subject to passive or overt homophobic comments and outright rejection. The fine line between healthy bonding and too much togetherness gets crossed repeatedly.

The holidays tend to be a time to make important announcements, but many in the LGBTQI community avoid coming out, introducing a new partner, or announcing they are transitioning due to a fear of rejection or a desire to not kill the cheer.

Although hugely liberating and therapeutic, coming out can be a difficult process. How one manages the stigma, fear, and degree of concealment can influence how easy or difficult the process will be. Individuals must prepare for a wide variety of reactions, including rejection, repugnance, violence and abuse, loss of support and resources, loss of employment, exclusion from legal and policy protections, and homelessness. This can come from family, friends, one’s workplace, faith communities, and many other areas of society.

Concealing one’s sexual orientation is often used as a coping strategy aimed at avoiding the negative consequences of stigma. But this can become a source of major stress and constant preoccupation, leading people to limit their friends, interests, and expression. Not only that, but it can also reinforce one’s fearfulness and belief of being different or inferior.

Self-stigmatization involves directing negative social values toward oneself, causing a person to view themselves from what they imagine is the perspective of someone else. This can cause a person to devalue themselves and can create internal conflicts and poor self-regard. This internalized homophobia may lead to self-harm, such as eating disorders and HIV-risk-taking behaviors. It may also affect intimate relationships and sexual function.

Those who conceal their sexual orientation are not likely to access formal and informal support resources, even within the LGBTQI community. This is extremely unfortunate, especially because members of the LGBTQI community are twice as likely to experience a mental health condition compared to heterosexual adults. Transgender people are 4 times as likely.

 Members of the LGBTQI community also experience higher rates of homelessness, substance abuse, and suicide.

It was not too long ago that homosexuality was considered a mental disorder. That changed in 1973, when it was declassified and removed from the second edition of the DSM.

Against this backdrop, the LGBTQI community has maintained a sometimes-uneasy relationship with psychiatry and the mental health field. Although all patients should receive unbiased care, there are clinicians who continue to discriminate against members of the LGBTQI community, whether consciously or subconsciously. As a result, many patients may avoid seeking the care they need.

LGBTQI members are more likely to have experienced traumatic experiences such as bullying, hate crimes, harassment, discrimination, prejudice, and family rejection. A 2019 school climate survey showed that 86% of LGBTQ youth reported being harassed or assaulted at school, which can significantly impact their mental health.

One survey found that 1 in 3 LGBTQI adults experienced mental illness compared to 1 in 5 heterosexual adults.

 Members of the LGBTQI community are at 4 times greater risk of depression and 2 times greater risk of suicide attempts, a rate even greater among teenagers.

 Suicide attempts among transgender individuals is a shocking 40%, compared to 5% of the rest of total population.

They also experience higher rates of substance abuse, with 40% of LGBTQI adults using illicit drugs in the past year, compared to 17.1% among heterosexual adults.

 There is also a greater potential for homelessness, with 20% of LGBTQI youth and young adults at risk of losing their homes, mostly due to rejection by family or discrimination. This risk is especially high among Black youth who identify as LGBTQI.

Combined, these health indicators point to a lower life expectancy among LGTBQI people living in stigmatizing communities. Studies indicate that repression and inhibition can negatively affect immune systems and result in poor health. On the other hand, expressing one’s emotions can actually boost the immune response and reduce adverse symptoms.

There are many ways members of the LGBTQI community can protect the spirit of the holidays this season. It all starts with a little self-care and efforts to surrounding yourself with people who are accepting and inclusive. This may also be the perfect time to create new holiday traditions. Here are just a few suggestions:

-Do not feel pressured to celebrate the holidays according to what others are doing. You deserve to prioritize yourself. Travel, buy yourself gifts, and do the things you truly enjoy.

-Seek help and guidance from friends or people you trust. It is important to talk about difficult or distressing feelings or emotions without fear of judgment.

-Likewise, offer support to other LGBTQI community members. Listen, reassure them, and show that you care. Providing support to others can boost your self-esteem and promote mental health.

-Limit time with family or antagonizing groups of people. Instead, make more time for the friends and communities that provide support. Create a sense of belongingness and community by seeking out LGBTQI-inclusive gatherings and celebrations.

-Do not abandon healthy routines. Make sure you get plenty of exercise and sleep and limit the use of alcohol or other illicit drugs.

-Limit social media engagement, if necessary.

-Get professional help. If you are struggling with mental health, reach out to a mental health provider, preferably someone with expertise in LGBTQI issues or who provides an LGBTQI-affirming approach to treatment.

Members of the LGBTQI community deserve to enjoy and celebrate the holidays just like anyone else. Yet, many are confronted with questions, judgement, and rejection. Instead of relaxing with family and catching up with friends, they may conceal their sexual identities or avoid uncomfortable gatherings, causing them to miss the opportunity to strengthen social bonds.

Members of the LGBTQI community—and anyone, for that matter—can preserve their integrity by practicing self-care and self-acceptance. Creating family by surrounding yourself with those who support you can go a long way in allowing you to relax, enjoy, and survive holidays.

1. Olito F. 15 surprising statistics about today's LGBTQ people. Insider. June 2, 2021. Accessed December 22, 2021. 

https://www.insider.com/surprising-statistics-about-lgbtq-people-2021-5#non-discrimination-policies-which-include-sexual-orientation-have-been-implemented-by-96-of-fortune-500-companies-9

2. Jones JM. LGBT identification rises to 5.6% in latest U.S. estimate. Gallup. February 24, 2021. Accessed December 22, 2021. 

https://news.gallup.com/poll/329708/lgbt-identification-rises-latest-estimate.aspx

Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. 

4. LGBTQI. National Alliance on Mental Illness. Accessed December 22, 2021. 

https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI

5. The 2019 National School Climate Survey. Gay, Lesbian & Straight Education Network. Accessed December 22, 2021. 

https://www.glsen.org/research/2019-national-school-climate-survey

6. Medley G, Lipari RN, Bose J, et al. Sexual orientation and estimates of adult substance use and mental health: results from the 2015 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. October 2016. Accessed December 22, 2021. 

https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.pdf

7. The report of the 2015 US Transgender Survey. National Center for Transgender Equality. December 2016. Accessed December 22, 2021. 

https://transequality.org/sites/default/files/docs/usts/USTS%20Full%20Report%20-%20FINAL%201.6.17.pdf

Finding peace, integrity, and new traditions despite discrimination and rejection.

Anoopinder Singh, MBBS, MD, FAPA

Articles

A Way Out of Seasonal Depression

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