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Hope and Health

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Hope & Health
Articles and Updates from WVU Medicine Children's

01/4/2024 | Maria Khan, PhD

Are you S.A.D.? What to Know About the “Winter Blues,” Depression, and Seasonal Affective Disorder

It’s that time of year again. With all the holiday joy behind us, the remaining cold, dark, and sometimes wet and sludgy conditions leave many in a slump. Adults and children alike can be subject to the “winter blues” – starting and ending our days in the dark, spending a predominant amount of time indoors, and having lower motivation and activity. Sure, winter can make us sad, but at what point is it SAD – seasonal affective disorder? It can be helpful to know the difference between signs of the “winter blues,” depression, and seasonal affective disorder (SAD), and how we can intervene.

What is Depression?

Depression, or major depressive disorder as classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; APA, 2022), is a mood disorder characterized by depressed or irritable mood, loss of interest or pleasure in activities, changes (increase or decrease) in appetite and weight, changes (increase or decrease) in quantity and quality of sleep, restlessness or excessively slow movement, loss of energy, feeling worthless or guilty, trouble concentrating, and thoughts of death or suicide.

For diagnosis, adults must display five or more symptoms, but children only require two or more symptoms for over two weeks. Depressive symptoms cause distress and impair functioning within home, work, school, social, or other settings. Notably, children experiencing depressive symptoms may indicate feeling more “annoyed” and “bored,” struggle to leave their room or bed, spend less time with friends or engage less in hobbies they used to enjoy, and experience dropping grades at school. Depression is highly heritable – children tend to be at greater risk if a family member has also experienced depression.

What is Seasonal Affective Disorder (SAD)?

Seasonal affective disorder (SAD) refers to a subtype of depression (as described above) which displays a recurring seasonal pattern, typically during colder months. SAD, also known as major depressive disorder recurrent with seasonal pattern (as classified in the DSM-5), requires at least a two-year period of depressive episodes during specific seasons only (e.g., depressive symptoms emerging in the fall/winter two years in a row with no symptoms during spring/summer). SAD can be described as looking like “hibernation.”

While SAD can mirror the depressive symptoms described above, there are a few distinguishable symptoms. Individuals struggling with SAD tend to withdraw, oversleep, experience greater fatigue or loss of energy, and have an increased appetite. Specifically, those with SAD typically eat more “comfort foods,” such as carbohydrates and sugars – foods which often result in increased fatigue and weight gain. While many of us may feel more lethargic when experiencing the “winter blues,” a diagnosis of SAD requires symptoms to cause distress and impair functioning within home, work, school, social, or other settings.

Research on SAD explains the impact of decreased sunlight on our brains. During colder and darker seasons, we can experience shifts in our circadian rhythms and sleep hormones (i.e., melatonin). As such, this phenomenon is overwhelmingly found in those living in northern regions. Interestingly, only 1 percent of Floridians suffer from SAD, compared to 10 percent of Alaskans (Knopf, 2018).

While SAD can affect individuals of all ages, research on children is limited. SAD tends to not become prevalent until adolescence and early adulthood (20s-30s). SAD, much like depression, is significantly more prevalent in women. Rates of SAD range from 1 to 10 percent in North America (Magnusson, 2000).

Diagnosing Depression and/or SAD

Mental health professionals (e.g., psychologists, psychiatrists, therapists) are skilled in assessing for symptoms of depression and other mood disorders. A psychological interview and depression-specific assessments (e.g., PHQ-9, CDI) may help to determine if a child or adolescent meets criteria for depression. The Seasonal Pattern Assessment Questionnaire (SPAQ) may be used for assessing symptoms of SAD, although this tool was only validated for use with adults.

Treating Depression and SAD

Evidence-based treatments for depression and SAD include psychotherapy and/or medication.

Cognitive behavior therapy (CBT) can help individuals better understand and recognize patterns between their emotions, negative and self-defeating thoughts, and unhelpful behaviors, which contribute to their depressive symptoms.

Psychotherapy for depression often promotes increasing behavioral activation – engagement in positive activities which enhance one’s mood. This may be particularly vital for those with depression and SAD who are struggling with fatigue, low energy and motivation, and loss of interest in pleasurable activities.

Anti-depressants, such as selective serotonin reuptake inhibitors (SSRIs), are commonly prescribed for depression in both children and adults. Studies demonstrated that SSRIs (e.g., Wellbutrin) may be helpful also in treating or preventing symptoms of SAD. Professionals routinely encourage a combined approach – both psychotherapy and medication – for best practice in treating depressive symptoms.

Treatment specific to SAD works to help regulate circadian rhythms. Bright light therapy – therapeutic daily exposure (20-30 minutes/day) to a brighter than average light via a light therapy box during fall and/or winter – has shown quick improvements in SAD symptoms (Campbell et al., 2019). Some individuals routinely utilize a more readily accessible “dawn simulator,” or a wake-up light that gradually brightens the room, as if to mimic a sunrise.

The mind-body connection is real! To stay mentally healthy, it is important to take care of general health and wellness, with a balanced diet, consistent sleep practices and good sleep hygiene, and regular exercise.

Parents are encouraged to model and teach healthy behaviors for their children. If parents become worried about the “winter blues” for themselves or their children, it may be helpful to incorporate joint activities into the family’s day-to-day routine (e.g., games, going on walks if weather permits, helping with homework, cooking together, crafts). It can be especially helpful for families to talk about and make plans to look forward to once the weather improves.

Suicide Risk

While it is not uncommon for youth to think about death, certain steps should be taken if a child or teenager expresses current thoughts about suicide. Professionals should always assess:

a) the frequency and intensity of suicidal thoughts b) history of self-injury and suicidal behavior or attempts c) whether the child has a plan (method and means) for suicide d) the child’s support system and reasons for living

A safety plan for managing suicidal thoughts should be completed with the child and caregiver(s). If there is imminent risk for suicide attempt, children and caregiver(s) are urged to call 911 and/or go to the emergency department immediately.

The following resources can be accessed 24 hours a day, seven days a week:

National Suicide Prevention Lifeline, call 988 Crisis Text Line, text “HOME” to 741-741

Child Depression Questions or Referrals

For concerns regarding children or teenagers with signs of depression or seasonal affective disorder, please feel free to contact the [WVU Medicine Children’s Behavioral Medicine and Psychiatry Program] at 304-598-4214.

About the Author

Maria Khan, PhD, is a clinical psychologist, clinical assistant professor, and director of the Resilience After Complex Trauma (ReACT) Clinic through the Department of Behavioral Medicine and Psychiatry at the WVU Rockefeller Neuroscience Institute. She is passionate about reaching under-served and vulnerable populations, such as children and families who have experienced adversity and exhibit heightened risk for a host of psychosocial and developmental difficulties. Dr. Khan provides evidence-based interventions for children and families experiencing depression, anxiety, behavioral problems, and attachment/relationship difficulties. She specializes in evidence-based therapies for children and families who have undergone traumatic experiences. Dr. Khan’s research interests revolve around child trauma and adverse childhood experiences (ACEs), risk and protective factors, and parent-child attachment in the context of child and family functioning.

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