Clare Oh

Your host Clare Oh is the Health producer of washingtonpost.com. Clare is in endless pursuit of ways to live healthier and improve her quality of life.

Many people--approxiamtely 20 percent of the population--experience psychological and physical changes caused by diminished light, either from overcast days or early night fall. Some, however, experience symptoms so severe that their lives are seriously disrupted by an unshakeable depression--lack of energy, disturbed sleep patterns and weight gain, just to name a few.

If you think that you might have seasonal affective disorder, or SAD, it is important that you seek medical assistance in dealing with this condition. Dr. Norman Rosenthal, a pioneer in the study of SAD and author of "Winter Blues" answers your questions about recognizing the symptoms and how to get effective help.

"Winter Blues"

Norman Rosenthal is currently a Senior Researcher at the National Institute of Mental Health and Clinical Professor of Psychiatry at Georgetown University. In addition to "Winter Blues," he also is the author of "St. John's Wort: The Herbal Way to Feeling Good."

Please read the transcript for this discussion below.

Clare Oh: Welcome everyone to Health Salad and to Dr. Norman Rosenthal, MD, a pinoneer in the study of seasonal affective disorder. Having experienced SAD himself, Dr. Rosenthal and his colleagues eventually worked to identify this disorder that affects millions of people. That said, let's begin.

E Greenwich, RI: I've heard of full-spectrum light therapy as an aid to SAD - some kind of light box for a daily dose of those friendly rays. Would you comment on this approach? I struggle so much with gloomy moods once the dark wintertime arrives...

Thanks - cheerful in sunny RI.

Norman Rosenthal, MD: This is a complicated question, because it mixes up light boxes and full-spectrum lights. Full-spectrum lights are those that mimic the exact spectrum of sunlight. Light boxes are metal frames that contain fluorescent tubes, which may or may not be full-spectrum. Light boxes can be tremendously helpful for the treatment of SAD, whether or not they contain full-spectrum lights. It is the brightness, not the spectrum of light that makes the difference to people with SAD.

NY: How do you recomend dealing with people who do not believe SAD exists? For example, I went to my General Practitioner to get some blood work done to eliminate the possiblity of anemia, etc. My GP insisted that SAD is a made up disorder, and that I should stop seeing my psychologist, etc. and start taking the medications he wanted to prescribe (on a first visit)!

Clare Oh: Hmmm, sounds like you may need a second opinion.

Norman Rosenthal, MD: In my experience some people just won't or can't change their minds once they have made them up. Don't even try - you're wasting your time. If your physician is helpful in other ways, that's great; if not, maybe it's time to get a new one.

Alexandria, VA: I have a history of SAD as well as mild depression. I have been off medication for two years as I had been planning to get pregnant. I am now in my early first trimester. Without medication, last winter was a little rough. I fear this one with the hormonal changes that seem to go along with pregnancy. I have talked to both my therapist and doctor and they aren't that concerned. Granted, I am overjoyed right now, but I still have concerns. Any advice?

Norman Rosenthal, MD: This is always a tricky situation. Ideally it is best if pregnant women can manage without medications. Light therapy is safe for pregnant women and there are many non-pharmacological ways to counteract depression - such as exercise, stress management, and good nutrition. If all of these still leave you feeling depressed, you may be best off using a medication, but of course a fine psychiatrist is the best person with whom to weigh the competing considerations

Clare Oh: Dr. Rosenthal, is it common for individuals with SAD to have had a history of depression?

Are some people more prone to having SAD thatn others?

Norman Rosenthal, MD: SAD is a common form of depression and people with SAD are more prone than others to suffer from other types of depression as well.

Burlingame, CA: What over-the-counter medication is available to individuals suffering from SAD?

Norman Rosenthal, MD: The best tested, over-the-counter medication for treating depression is St. John's wort. This herb is an effective antidepressant and has a good side-effect profile. You should consult your doctor, however, if you are on any other medications as it may interact with other medications. I do have a book out on the herb, called St. John's Wort: The Herbal Way to Feeling Good (Harper Collins, 1998). Other over the counter substances, such as fish oil capsules and SAM-e are less well tested.

MD: How and when did you notice that your disorder was seasonally-related? Did you encounter any difficulty in explaining to family/friends?

Clare Oh: Good question. Dr. Rosenthal, tell us about your expereince with SAD and when you first noticed it. And I know you talk about it a bit in your book.

Norman Rosenthal, MD: I first noticed my SAD when I arrived from South Africa to do my residency in New York City. I had to go through three winter depressions before recognizing the pattern. Then I came to the National Institute of Health, where my colleagues and I described SAD and developed light therapy as a treatment for it. Finally I decided that I needed to tell the readers of my book Winter Blues (Guilford, 1998) that I too suffer from SAD. My patients have given so much to our understanding of the condition that it was the least I could do. Everybody has been wonderfully understanding about it - and many of my friends and family members have come forward to tell me about their SAD as well!

Clare Oh: The NIH is currently conducting research on the efficacy of St. John's Wort. Are there any precautions one should take while taking this herbal medicine?

Norman Rosenthal, MD: As I mentioned, the most important thing is to be sure that if you are taking other medications, that your doctor knows about the use of St. John's wort - as it may lower the levels of several different medications. People on St. John's wort tend to become more sensitive to sunlight and should be careful of exposing themselves excessively to sunlight. Otherwise the herb is pretty safe.

WDC: Dr. Rosenthal, do you have any nutritional advice to help counteract some of that SAD?

Clare Oh: Another good question. On the whole, healthy diets chock full of fruits and vegetable and meals with little fat will make you feel less lethargic. Dr. Rosenthal, you mentioned something about the paradoxical effect of carbohydrates in people with SAD. Can you tell us about this too?

Norman Rosenthal, MD: There is some evidence that fish oil may have antidepressant effects - not codliver oil, but omega-3 fatty acids - 3 grams per day of these omega-3's should be sufficient. Multivitamins may be useful too.
When it comes to carbohydrates, people with SAD (me included) just love them - but they should be limited, perhaps to one meal a day - otherwise the weight will just keep piling on

Clare Oh: What are some of the other studies going on right now regarding SAD?

Norman Rosenthal, MD: Unfortunately these are SAD days for SAD research. Funding has been cut back severely and it is not currently considered a research priority. Even so, some of the more exciting developments are the ongoing quest for genes for SAD, and studies of patterns of the hormone melatonin, which seem to be different in SAD patients as compared with controls.

Alexandria, Virginia: I can remember being in college and suffering from what I then called "the Februaries." I really hated the cold, dark days of winter. In the little I have read about SAD, I think I might have it. What are the symptoms? What are the "cures"...I REALLY do not want to take Prozac/zoloft/whatever. Thank you

Norman Rosenthal, MD: The common symptoms of SAD are:
- slowing down in energy
- need for more sleep
- craving sweets and starches
- weight gain
- low mood, sadness, anxiety or irritability
- difficulty concentrating
- withdrawal from friends and family

Adams Morgan DC: I often experience depression, but it becomes a more severe depression right after winter. I have heard that this is not that uncommon. Once the weather turns warmer and sunnier it seems that I should be happy that I got through winter but in reality my life is pretty much the same.

Any thoughts on how to avoid this in the future?

Norman Rosenthal, MD: Spring is a very common time for depression - as TS Eliot put it, April is the cruelest month.
Spring depressions usually need to be treated medically if they are severe; in some of my patients we anticipate the spring difficulties and start medications ahead of time

McPherson Square: I don't believe I have SAD, although I do get mildly depressed (maybe upset is a better word) when the sun sets before 4:30 or 5. It just seems so dreary to me. What advice would you give me?

Thanks.

Norman Rosenthal, MD: There was a doctor who gave a special term to your type of melancholy - Hesperian depression, named after Hesperus, the Greek goddess of dusk. I would try using bright light at the end of the day to see if you can fool your brain into thinking you have an extra hour or two of daylight

Alexandria, VA: I suffer from SAD, and have had good luck using a light box. It makes an amazing difference to my winter and I would recommend it to anyone!! My light box is about three feet by two feet and VERY VERY heavy, difficult for me to move from room to room by myself. Do the smaller light boxes (i.e. desk size) work as well as the large ones? If yes, where can I find them?

Norman Rosenthal, MD: I'm so glad you asked this question. There are some wonderful newer light boxes that are much smaller and handier. They are also cheaper. One problem with them though is that they do give off less light, so it is a bit of a trade-off. It may be nice to get a smaller one to carry around and supplement your older larger box. One local company, The SunBox company provides many different models and has been doing business with SAD patients for years. Other companies are listed on my web site at www.normanrosenthal.com or in my book "Winter Blues."

Clare Oh: Dr. Rosenthal, it's still quite difficult to get employers to accept mental health as a priority. How does one go about dealing with SAD in the workplace?

Norman Rosenthal, MD: I have had most success with my patients by providing them with letters certifying that they have SAD and need special accommodations, which may range from being able to use their light box at work to having an office with a window. According to the American Disabilities Act, workers are permitted reasonable accommodation for illnesses. If a workplace is hostile to the idea of a person with SAD, though, some of my patients have had more luck changing jobs.

Baltimore: Are there any special light bulbs that can counter SAD?

Clare Oh: I think this person may mean instead of buying a light box.

Norman Rosenthal, MD: Light therapy involves the use of special BOXES rather than special BULBS. Many people have tried to help themselves by changing the light bulbs in their homes to absolutely no avail.

Alexandria VA: How many lumens, what frequency of light, how much time is needed per usage, is it an eye thing, is it a skin thing, would it be better if it is a skin thing to expose most all of the body to this form of radiation.

Norman Rosenthal, MD: It seems to be an eye thing - or so research tells us. Typical light boxes put out between 2500 and 10000 lux (the way in which light is commonly measured). Duration is variable, depending on the individual's needs and the time of year. One thing that has emerged from studies is that MORNING is generally the best time for light therapy.

To Alexandria: "Februaries" = good description. So true.

Someone once told me that we start gaining afternoon sunlight in early December, if that is of any comfort...

Clare Oh: Yes, and we start losing light in early August.

Norman Rosenthal, MD: One problem with January and February is that even though the days are getting longer, they are also our cloudiest months and therefore the dreariest. The holidays are over and there seems to be nothing to look forward besides the blessed groundhog. That's why these are good months to go south for a vacation if you possibly can. And plan that in advance. By the time February rolls around, one can be too depressed to make the necessary arrangements.

Rockville, MD: Hi Dr. Rosenthal,

I own a light box that I use at my office. I'm wondering if there are guidelines regarding the amount of time you should have the light on during the day and if so, what this is based on. I'm also wondering if the light has to be directed at your face in order for you to experience the benefits.

Thanks!

Norman Rosenthal, MD: Most people with light boxes in their offices use their own judgment as to how long to use them for. There are no official guidelines. One tip though - if you find yourself getting too buzzed (sort of like drinking too much coffee) you have probably had too much light and should turn it off for a while. Also, be careful about too much glare if you are using your computer screen as it may strain your eyes excessively.

Rockville, MD: Does outside temperature affect SAD? I have read much about the fact that many people with SAD get the "blues" on cloudy days whatever the season, but I experience SAD not only in the winter but on unseasonably cool days in the spring and summer, whether it is cloudy or not.

Norman Rosenthal, MD: I have not heard of cool bright days causing SAD, unless it keeps one indoors so that you cannot enjoy the sunlight. One thing to consider is whether your thyroid is functioning adequately. People with underactive thyroids have a hard time tolerating the cold - and it is a condition that can be diagnosed by a simple blood test and treated by simple replacement therapy.

Alexandria, VA: Dear Doctor, this is so interesting. Thank you. What dosage of St. John's Wort?

Norman Rosenthal, MD: The usual dosage of St. John's wort is 300 mg three times a day, though once or twice a day may be fine as long as the total is 900 mg. Take it with meals to minimize stomach upset.
One tip: The brand does make a difference as herbs are not too well regulated. My favorite brand is Kira - a German brand currently being used in the NIMH trials. It is available from drug stores rather than from health food stores.

Arlington, VA: Is it always necessary for a person with SAD to go on antidepressants?

Also, why is SAD so hard to diagnose? Seems like it gets mixed up with other conditions.

Norman Rosenthal, MD: SAD is only hard to diagnose if you don't think of your life as cyclical. If you look back and ask yourself, how do I feel at Thanksgiving, Christmas etc. Am I different in the winter than in the summer, then it is not hard to diagnose. If you think only of "What happened last week?" then you will miss it.

Columbia, MD: You mentioned St. John's Wort as an effective over the counter. I agree. But do you think about the new reports that it may interfere with drugs such as birth control, anti-organ rejections, AIDS drugs?

Depression stinks, but better that than unwanted pregnancy. I quit taking that stuff.

Clare Oh: Dr. Rosenthal, I think our reader brings up a good point: what about the news that St. John's Wort interferes with the efficacy of birth control pills?

Norman Rosenthal, MD: Yes, yes, yes
Once again, beware of St. John's wort if you are taking other medications. These include AIDS drugs and oral contraceptives as our well-informed questioners point out.

Washington, DC: Would you say people that suffer from depression are more susceptable to SAD or equally as susceptable to SAD as any person?

Norman Rosenthal, MD: This is a difficult question as SAD is a type of depression. It may affect those who are and those who are not depressed at other times of the year.

WDC: How do societies in extreme northern/southern areas handle the seasonal lack of sun? I understand Alaska is pretty brightly lit. Have you noticed other areas that try and consider this problem?

Norman Rosenthal, MD: All sorts of interesting ideas have been devised - from special lights on buses in Finland to very bright street lights in Siberia. Remember, many people do not have SAD and do fine with the darkness. I remember one visit though to Tromso, a city north of the Arctic Circle. I forgot to have a light box on hand and it was weird to feel the energy drain out of me shortly after arriving there. Luckily Jennifer Eastwood, president of the SAD association of Great Britain had had the foresight to have a light box on hand and the dear lady let me share hers!

Arlington, VA: Dr. Rosenthal, how can one deal with the effects of SAD on a day-to-day basis in the winter time without having to see a professional?

Norman Rosenthal, MD: This is tricky - because each day brings new challenges. At the risk of self-promotion, I would recommend my book Winter Blues as a survival guide to SAD from one who has lived it, studied it and treated hundreds of patients with it. If I could give you one tip, it is to constantly remember to get enough light.

Fairfax, VA: Re: Alexandria, VA's question: Just wanted to pass along my experience re depression & pregnancy. I too suffered with SAD and mild-to-moderate depression most of my life. When I became pregnant and especially after the first trimester, I realized that the "pregnancy harmones" seemed to have a very positive effect on my well-being in that I didn't suffer a single episode after my first trimester. It was the most contented period of my life, loved it! It sounds as if she will give birth during next spring/summer, which is great because of the real concern here of post-partum depression. Since my daughter was born in the fall, I suffered a great deal with the post-partum depression, which seemed to be made worse with the dreariness of that time of year.

Norman Rosenthal, MD: This very nice comment goes along with my experience that many pregnant women who have previously suffered from depression seem to manage fine through the pregnancy. It is good to have an understanding doctor to help one through though and to know that help is available if necessary.

Washington, DC: This may sound wacky, but are there other seasonal variations than sunlight that impact mood significantly? I ask because I find that summer is actually the toughest time for me -- I've joked with friends that I've just never gotten used to not having summers off, but the truth is, my energy level plummets and my mood goes south with it. Then fall rolls around, and the brisker weather (like this week!) and just the restless mood of it lift my spirits immeasurably.

I suppose all sorts of entirely subjective factors could be influencing my particular mood, but its such a noticeable pattern that I wonder if there isn't a less subjective basis. Possibilities -- allergies, lethargy-causing heat, etc. Have you come across others with a similar pattern?

Norman Rosenthal, MD: Summer depressions - though not as common as the winter variety - are very well described and can be very difficult. Although it helps to keep cool, there is no "cold therapy" for summer depression that works as well as light therapy for winter depression. Mostly people with marked summer depressions end up needing medicines, which are most effective if used early to pre-empt the worst of the symptoms.

Alexandria, VA: Good Doctor:

I asked before, and it was just asked again...PLEASE answer. Does SAD require use of prescribed antidepressents? I sooooo hope not.

Thank you

Norman Rosenthal, MD: Sometimes it does and sometimes it doesn't. It depends on the severity of the symptoms. Sorry that there is no simple answer. One consolation is that so many people do well with medications that even if your SAD requires them, you may do just fine

Reston: You mentioned April is the cruelest month. I always thought it was harder during the winter months, but really looking back on it, getting into summer has been the hardest. Why is that? Seems like we should all be grateful for the lovely weather and sunshine...

Norman Rosenthal, MD: For over 100 years, researchers have disputed why spring is such a difficult time. It seems most likely that some people have a hard time making the physical and mental adjustments to the rapidly changing daylength and weather.

Washington, DC: Unrelated to SAD, could you let me know what your thoughts are regarding the efficacy of anti-depresants, namely Prozac, after many years of use?? After many years, should people consider switching from one SSRI to another, perhaps?

Norman Rosenthal, MD: If it aint broke, don't fix it. If Prozac still works after many years - as it often does - leave well alone; if symptoms break through, a change is warranted.

WDC: Can children develop SAD? IS it treated the same way as for an adult? I fear having to give a child drugs to combat depression.

Norman Rosenthal, MD: Children certainly can develop SAD - in fact I have a whole chapter in my book on SAD in children and adolescents. Often the SAD can be treated by light therapy alone, as well as a device known as a dawn simulator, which can be helpful for SAD in both children and adults. This device turns the bedside lamp on gradually, thus simulating a summer dawn. It is also available at SunBox Company. For those who are unable or unwilling to pay the price of this device (between $100 and $200), a simple timer attached to a bedside lamp is a handy alternative.

Clare Oh: In your opinion, do you think that primary care physicians are well-equipped with the knowledge to identify and correctly respond to symptoms of SAD?

Norman Rosenthal, MD: Primary care physicians are so variable. Some are just wonderfully well informed whereas others, like one mentioned earlier in the program, just don't believe in SAD. That is why I use the slogan of a popular discount clothing store in telling my patients and readers that an educated patient is the best consumer.

New Jersey: Is it possible to never had any previous problem associated with SAD and then develop it later on in life?

Norman Rosenthal, MD: This is possible, especially if:
1. You have moved north
2. You have changed jobs or dwellings so that you are now getting less light; or
3. You have developed some difficulties with vision

VA: I wonder if there is any politically correct way to help someone with SAD get help?

Norman Rosenthal, MD: I always find referring to seasonal cycles in nature to be very helpful - you know, bears do it, birds do it; let's do it; let's diagnose SAD and get some more light!

WDC: What is the difference between SAD and simply the Winter blues?

Norman Rosenthal, MD: It is really just a matter of degree. Many people are seasonal; those with extreme seasonality who have difficulty functioning in winter are said to have SAD; those who simply feel some drop off in creativity, productivity or quality of life are said to have the winter blues. Either way, the same treatments work for both conditions.

Gaithersburg, MD: I've heard over and over that light therapy is the best choice for treating SAD. Is this view shared by health insurance companies? Will they cover light therapy boxes? If not, how would one convince an insurance company to cover Norman Rosenthal, MD: Insurance companies are variable in their willingness to cover light boxes, but it's worth a try. In my book I have TWO sample letters for insurance reimbursement. Remember, these companies are often more concerned about cost than quality of care. They may think it in their interest to judge light therapy to be "experimental." Actually, by saving on medications and doctors' visits, light therapy saves a great deal of money, not to mention human suffering

Clare Oh: Thank you Dr. Rosenthal and everyone who sent in a question. Next week's discussion is on cancer prevention. Until then, be well.