Jan. 10, 2022

SAD = MDD: Medical Fact or Mythical Beast?

Seasonal affective disorder is estimated to affect 10 million North Americans and is four times more common in women than in men. Some people experience symptoms severe enough to affect quality of life, and 6 per cent require hospitalization
seasonal affective disorder
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Just stop for a moment. Here we are in 2022, still coming out of the fourth wave of a pandemic, now battling the Omicron variant, and we’re stuck in the middle of another Canadian winter with nowhere to go!

How uplifting is that? 

But let me back up: As a lasting legacy of a 2010 tour across Canada, during which I spoke about depression and fighting the stigma behind mental illness, I am often asked at this time of year about SAD (Seasonal Affective Disorder). This is both a personal and professional story for me.

SAD is now more correctly termed MDD (Major Depressive Disorder) or Seasonal MDD, a diagnostic subset of depression. Others may call it the “Winter Blues,” but that just makes me want to sit at a piano and pound out a mournful 12-bar tune. Which isn’t a bad idea, come to think of it . . . 

A lot of Canadians can get more than a bit of  “cabin fever” during the long cold winter months. But the common experience of being miserable should not be confused or undermine the diagnosis of a major depressive episode.  

Seasonal MDD is easily diagnosable. Its unique features are a serially repetitive and cyclic depression that relapses and remits based on the season. For most, the season in question is winter, from late autumn to spring. Some people begin to experience a “slump” as early as August, while others remain well until January. Regardless of the time of onset, most people don’t feel fully “back to normal” until early May.

The origin is all about the light cycle — the distinct difference in hours of daylight in summer versus winter. It’s the same neurochemistry that triggers bears to hibernate and birds to migrate. While there are a lot of theories, the dual vulnerability model seems to make the most sense. If you happen to have the genetic (animal brain) and live at the “wrong” latitude (i.e. farther from the equator), you are more likely to suffer. It’s not about a sunny versus predominantly cloudy climate — although, I must profess, I prefer a sunny cold winter day over an overcast milder one. There might be a reason that this Winnipeg boy ended up in Calgary and not Vancouver. 

While the majority of seasonal MDD sufferers experience a mild depression, there is a distinct group in which the depression is moderate or even severe enough to impair cognition and elicit suicidal thoughts. Some clinicians might dispute this severity and, therefore, the whole idea of this particular diagnostic group. It’s just Canadian winter, they may say, “so suck it up; it will be over in a few more months . . .” There are others who believe this is better characterized within the realm of bipolar affective disorder. I disagree. This is a “unipolar” depression that, thankfully, eases in summer. 

Symptoms of seasonal MDD include hypersomnolence (excessive sleepiness), increased appetite and weight gain, and generalized fatigue. Think of a bear heading off to hibernate. The patterning is quite consistent and parallels postpartum depression in its potential predictability.  

I’m a strong proponent of multimodal therapeutics, so I have created a mnemonic to help: “SAD LAMP.” I guess it creates controversy from the start in that it highlights (pardon the pun) the potential use of light therapy, which is not always crucial to the success of therapy. 

Here’s a breakdown of the acronym: 

S = scheduled 

AD = anti-depressants 

L= light therapy, lifestyle (that is, a lower carbohydrate diet and regular exercise).

AM = alternative medical therapies (which can include omega-3 fatty fish oils and appropriate vitamin D) .

P = psychologist (or any mental-health practitioner with cognitive behavioural therapy (CBT) skills – this is a very commonly used and highly effective psychologic treatment method).

Everything mentioned in this mnemonic should be supported and readily available at any wellness centre or mental health service. The exception would be the use of prescription pharmacologics which would require the involvement of a family physician or psychiatrist.

As this condition is cyclical (and winter happens every year, even with global climate change), we need to schedule therapy to start in the fall — but even January is not too late! Stimulating (or at least non-sedating) anti-depressants should be deployed if your case of MDD is moderate or severe. Light therapy is beyond the scope of this article but can certainly be used — first thing in the morning for at least 30 minutes most days of the week. The effective therapeutic role of exercise cannot be understated. I have personally been very healthy mentally for more than a decade due to regular exercise (and avoiding depressants such as alcohol).  

In addition to what is stated above, the “L” category could also include doing what you love (behavioural activation), being social and doing things that make you laugh. While I believe that most Canadians could benefit from a vitamin D supplement through the fall and winter for their immune systems and bone health, lack of the vitamin is not the underlying problem of this diagnosis. I wish vitamin D supplementation was the cure for seasonal MDD, but it is not. This, too, is a subject for its own article.

I still find the working knowledge of many practitioners to be rudimentary in dealing with those suffering from seasonal MDD. While the public is mostly on board, there are still too many cynics who offhandedly dismiss this condition. As we know, depression has significant physical and mental manifestations that can have a huge negative impact. It can affect our cognition, work and social lives, and be highly dangerous if suicidality enters into the clinical picture. 

If socializing is healthy and something we love to do (still another “L”), COVID has been devastating to these activities. People struggling with seasonal MDD tend to shy away from getting out and socializing with others through the winter and this pandemic has encouraged isolation and this negative behaviour. Decreased mood and increased anxiety have been hallmarks for many through the last two years.

The hallmarks of depression are persistent low mood and anhedonia or a lack of interest in activities that are pleasurable. Other symptoms include cognitive impairment, feelings of guilt or worthlessness, lack of energy, appetite changes, psychomotor changes – higher or lower, sleep disturbances or suicidal thoughts. If any of this sounds familiar in yourself or in someone close to you, you should seek professional medical or psychologic attention as soon as possible.

I’m a survivor of mental illness and I don’t feel a need to hide this fact. I have learned the hard way that acknowledging my limitations and having an aggressive plan in place to help manage my mental health and wellness has allowed me to thrive and be happy. SAD no more! 

Dr. Ted Jablonski, MD, is a singer-songwriter, emerging playwright and neophyte poet who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta. He now finds himself advising medical students at the Cumming School of Medicine and is back in the trenches, as a clinician and medical lead of a clinic managing COVID-19 cases.