Amanda Wilde (Host): Being nestled in northern Pennsylvania, nobody at Guthrie is a stranger to the beauty as well as the challenges of all four seasons. With that in mind, we're diving into the topic of Seasonal Affective Disorder, or SAD, with Clinical Health Psychologist Dr. Danielle Terry. Dr. Terry is Director of Behavioral Science with Guthrie Family Medicine.

 This is Medical Minds, Conversations with Guthrie Experts, a podcast from the Guthrie Clinic. I'm Amanda Wilde. Welcome, Dr. Terry. It's so great to have you here. Perfect timing.

Danielle Terry, PhD, ABPP: It's great to be here.

Host: We often hear about seasonal affective disorder this time of year. Can you break down exactly what SAD is and how it's different from other forms of depression?

Danielle Terry, PhD, ABPP: Sure. You know, sometimes I really like to clarify the terminology that we use. So a lot of us folks in the community, in the general public, we refer to SAD, Seasonal Affective Disorder, in our common language. And if you actually look at diagnostic criteria back in 2013, the manual of mental disorders that we use, they changed SAD to actually being a seasonal specifier for a type of depressive disorder. That was maintained in 2022. So now really us clinicians, we call it major depressive disorder with a seasonal pattern. So you can think of depression or bipolar as the umbrella. And under that umbrella is that subtype of that disorder that really expresses itself with a seasonal pattern.

So if you were talking about depression in general and what it looks like; someone who has depression is going to have at least some, not necessarily all, but a lot of symptoms. They have to have them for a minimum of two weeks. Most people have them for much longer, but it's symptoms like having a sad or irritable mood.

They might have less enjoyment in their activities, less pleasure that they get out of activities they normally would like. They might have problems with sleeping. So that could be problems where they're sleeping more than usual or sleeping less than usual. Problems with their eating or their appetite.

So they may be again, eating more or eating less. They may notice feelings of hopelessness. They might have physical agitation in their body, that feeling that you get when you want to just crawl out of your skin or the ants in your pants kind of feeling, and they might notice more guilt or excessive guilt and feelings of hopelessness, concentration problems and sometimes you'll see folks who have experiences of thoughts about dying or suicide.

And, when you think about seasonal affective or seasonal patterns to these; people who present with depressive disorder, with a seasonal pattern, they show at least some of these symptoms, but typically their symptoms are really going to be occurring in the fall and winter months when there's that reduction in light, and then it's going to ease up when spring comes.

So fewer people might experience the depressive pattern when they go into summer. But they can, it is possible. I always like to note that depression can be agitating. But when you're talking to somebody who has that fall or winter onset, you might see what I'd call more of the Eeyore type of depression.

When you think of, remember Winnie the Pooh? There's that character Eeyore. And someone who shows that increased sleep, the carb cravings, the increased appetite, that weight gain. If you saw someone experiencing this in the summer, spring onset, it tends to be more of that agitated depression with more insomnia, more appetite, more weight loss.

Host: So are you saying seasonal affective disorder can also happen at other times of year than what we typically think, winters?

Danielle Terry, PhD, ABPP: Yep, absolutely. You can see it transition in a seasonal pattern when you're going from, springtime, spring to summer.

Host: And, I imagine like with the weather, can range from mild to severe. Is SAD like that? Do people experience varying degrees SAD?

Danielle Terry, PhD, ABPP: Absolutely. I mean, sometimes people talk about seasonality. So those are those seasonal changes that we see in mood, and we could think of seasonality being on a continuum of severity. So, seasonal depression is at one end of that continuum where you're going to see really severe symptoms or more severe symptoms and it fits into a category that aligns with being clinically depressed.

And I always think we can compare mental health conditions to physical health conditions. So, just like you see varying degrees of severity and symptoms and their impact on functioning. So you might see somebody who has cancer that's easily removed, margins are clear with just a little removal and a couple of stitches. You can also see somebody who dies from cancer. You can see someone who has resistance to treatment with cancer or someone who's living with a chronic condition due to recurrent or metastatic disease. And when we think of depression, we can think of it as a disease process in a similar way. So you might see someone who has significant symptoms, but they function fairly well on a daily basis.

You might ultimately see someone who dies by suicide due to the severity of their symptoms. And just like with physical health, you might also see some of those underlying risk factors or vulnerabilities that result in greater distress or dysfunction. So even if someone had fewer symptoms than another person; the way in which that emerges in their life can actually be quite different.

Host: There seems to be a growing conversation around depression, including SAD, in recent years. Have you noticed an increase in cases? Are people coming to you with those kinds of concerns about anxiety, depression, and mental health issues that are seasonally related?

Danielle Terry, PhD, ABPP: Well, it's possible, you know, in the general population, you're going to see about a half a percent to three percent of people who might have seasonal depression in their lifetime. Where if you look at major depression in general, you're going to see about 21 percent who have major depression at some point in their lives. If you look at what the CDC, the Centers for Disease Control and Prevention have talked about, there was almost a 15 percent increase in depression during the pandemic.

And we've continued to see an increase, which really isn't that surprising given that we had such a major disruption for that three year period.

And for younger adults, if you think about when that disruption was occurring during their development, that was a pretty important time and so that may have set up folks who were vulnerable already to being at risk for developing more problems. And so you can think of all of this and now think of all of this within the context that we have, which is there's been some culture shift when it comes to people being more aware of depression.

People tend to be more likely to acknowledge it and be more likely to reach out for help. So even though we've seen these increases, some of it may be pandemic related, but also we have a context that's a little more forgiving when it comes to mental health compared to where it used to be many years ago.

Host: Yeah. I was gonna ask you if there are any specific triggers or factors that contribute to SAD and if there is an upward trend, which there is, what that could be, but I think you've covered that, just circumstances. And everything's shifting around us. And so that unbalances a lot of us. When we think about mental health, it's a complex puzzle. So, let's talk about how SAD fits into that picture. Like what role does managing the seasonal disorder play in the overarching mental health care plan?

Danielle Terry, PhD, ABPP: Well, any time you're thinking about these symptoms and the seasonality of them, or if you're even diagnosing depression or any other mental health concerns, you really need to think about any physical conditions that could account for the symptoms. You want to make sure those are ruled out. You'd want to consider what other conditions or experiences might be making the symptoms worse and making treatment more difficult.

 So when someone has awareness that there is a seasonality to their symptoms, so they know, okay, fall, winter is coming, it's going to be difficult, or more difficult than usual for me, for whatever reason, and whether it's meeting clinical criteria, or it's just a mild flare in that distress or difficulty; it's, I think, a really great thing to be taking note of the pattern, partly as the provider, but also as the individual. So they can anticipate their needs, coming up with a plan or even just expecting that there's going to be more symptoms because when we're caught off guard, we often struggle more, because we're not anticipating that need.

So I think sometimes we want to look at that broader picture and really try to anticipate the pattern.

Host: Yeah. The anticipation and then from there to prevention, in your experience, are there steps people can take to reduce their chances of being affected by seasonal affective disorder?

Danielle Terry, PhD, ABPP: I would say so. I mean, there's the prevention, but then there's also the response to, and there are a lot of things that people can do to help themselves. It's really based on what they're going to tolerate and what they're willing to do. And my emphasis whenever I talk to people about this, is that they don't have to sit around and suffer with symptoms.

If we had an individual with cancer, diabetes, another medical condition who didn't want to assess or treat their symptoms, that's their choice. But there's no medal at the end of all of that for trying to power through and avoid treatment. And the same thing goes for mental health.

And so to the contrary, we'd really hope that people would work to alleviate their symptoms. People would work to try to help themselves and a lot of people, especially when it comes to mental health, they subscribe to the power through model because although we have had more forgiveness in our culture, and more openness to approaching mental health; a lot of folks will see mental health as them being weak or silly or even making unnecessary complaints. And so you don't have to suffer with those symptoms and they don't have to suffer without treatment. But, there are a few things that you can do for prevention. First off, if someone has a consistent pattern of depression that they're aware, that may sneak up on them come fall and winter; they can always consider increasing if they're on an antidepressant or starting medications, you know, they collaborate with their provider to determine that. And you can consider using artificial light, light therapy, which has evidence behind it. It's a reasonable treatment. People sometimes like that because it avoids use of medication.

You can always start light therapy several weeks before the seasonal change. So you can get that going underway. And there is some evidence actually to suggest that that could be helpful for non-seasonal depression as well. But if your depression turns severe, that's unlikely to be enough.

And so there's also dawn simulation, which is kind of that simulating the sunrise, artificially. And that shows about the same efficacy as the bright light therapy. Other options that they could consider starting either in a preventative way or getting a booster if they've already done it before or starting it brand new would be things like trying out cognitive behavioral therapy which is an evidence based therapy to help with depression.

For folks in general, I always suggest behavioral activation. Which is really just coming up with a plan of what are the things that you can have active in your life that you're doing to help yourself and your mood that bring you pleasure. Aerobic exercise is another one. So, using this activity scheduling as a preventative measure.

If they just get the blues, they're not clinically depressed, I say come up with a game plan for the winter. What do you enjoy? What do you like to see? Who do you like to see? What are some of those smaller things you like to work on? And then asking yourself the question, well, when was the last time you actually did that?

If it's a long time, then get it in the calendar. If it's already in the calendar, wonderful. But get that set up so that you have an actual plan because when people give into that desire to hibernate, and to avoid those activities, they're not even going to have the opportunity to feel better. So, what we need to do is override the reluctance sometimes with the goal of not making that problem worse.

Host: A lot of this sounds like it's about understanding or foreseeing your own patterns and planning and doing the things that will support your mental health in advance, as we talk about prevention. But if you are in it, can you talk about some resources for treatment?

Danielle Terry, PhD, ABPP: That's the thing, is once people start noticing those symptoms, like I've said, I think there's absolutely effective and evidence based treatment they can get help with. Now, if you're in an emotional crisis, we do have the national crisis line that exists. You can dial 988 on your phone, just like we use 911, you can dial 988, which is the crisis line.

And that's a 24 hour, 7 days a week, free confidential support line. They're going to help direct you to where you need to get to. There are also some resources on their website. So that's 988lifeline.org. The other thing I say is talk to your doctor, most people go to their primary care physician as their first defense or first line of treatment, even over a mental health provider, where you can start the discussion saying, Hey, I've noticed some symptoms, I've been struggling. You can get some maybe additional resources and support.

Another place if you're interested in therapy is going to psychologytoday.com. That usually has a list of providers and many different filters so you can screen by your insurance type. You can screen by what specific problems or background or characteristics or qualities you're looking for. And also by your geographic region.

There's a lot of good telehealth treatment options out there. And there's a few good workbooks that people can also use if they want to go self-help. So I always like the workbook Mind Over Mood, which is a cognitive behavioral therapy workbook as well. So those are some basic options, but if someone's in a crisis or experiencing suicidal thoughts or is just feeling out of control and like they really need to seek help, then dialing 988 is really the best option.

Host: That is really good specific information. It is really important to know what support is available for all degrees of depression. Dr. Terry, thank you so much for this important conversation about SAD and mental health.

Danielle Terry, PhD, ABPP: Oh, thank you. It was absolutely my pleasure to join.

Host: That was clinical health psychologist Dr. Danielle Terry. Dr. Terry is Director of Behavioral Science with Guthrie Family Medicine. To learn more, go online to guthrie.org/mentalhealth. If you found this podcast helpful, please share it on your social media. This is Medical Minds Conversations with Guthrie Experts, a podcast from the Guthrie Clinic.