Cheryl Martin (Host): It's that time of year again. The days are short and cold, and the effects of winter blues or seasonal affective disorder can kick in. Family physician Dr. Christopher Ricketts is here, to share insights on how to deal with, and hopefully beat, the winter blues. This is Woodlawn Health DocTalk, a podcast from Woodlawn Hospital.

I'm Cheryl Martin. Dr. Ricketts, great to have you on. 

Christopher Ricketts , MD: Thank you, Cheryl, for hosting me today. I really appreciate the opportunity to be with you.

Host: So first, what are the primary symptoms of seasonal affective disorder, or SAD, and how can they vary among individuals? 

Christopher Ricketts , MD: Interestingly, symptoms can present in a variety of ways for different people. One main distinctive from classic major depression is more in the seasonal part of the definition of seasonal affective disorder.

More than the symptoms, there's a lot of overlap between the two disorders. But we certainly feel and identify seasonal affective disorder more with the colder seasons, when the days are shorter and we just don't get out in the sunlight like we normally should. And often this can trigger for a lot of people, various symptoms like sadness and hopelessness as well as, feelings of guilt and grief and emptiness. 

It's something where by definition, we think of it in the wintertime, but interestingly, actually somewhere on the order of about two to five percent of seasonal affective disorder actually occurs in the beautiful summertime months. 

Host: How many people, when they have these symptoms, initially associate it with the season? 

Christopher Ricketts , MD: There are a lot of people who are really insightful and have a good grasp of their personal health and well-being. So I think there are a lot of people that really recognize that during the winter months, they just don't quite feel quite as good or peppy or energetic or with it or what have you, as they do during the summertime months. 

Host: What are some common misconceptions about SAD and then how can they be addressed during a patient consultation, for instance? 

Christopher Ricketts , MD: The biggest thing, and I think this is just a generalized answer that can be applicable to everything in healthcare, which is just honesty and full disclosure. I, or your healthcare provider can't help you if there isn't good open communication and for me, whenever I'm seeing someone, regardless of the situation, there are always those key sentiments or words that people say that I'm listening for, in order to try to work with them to try to find both a proper diagnosis and then with that a proper treatment. That's actually one phrase that I use quite often with people which is, proper diagnosis is important to proper treatment, and I think there really can't be a realistic expectation for healing if we don't really have a full grasp of whatever the circumstance is.

Sometimes this comes to light pretty quickly. Sometimes it's very obvious and sometimes it just takes a lot longer. Sometimes it takes many visits even to get a full grasp of what a particular person's struggle is at that time. 

Host: What do you see as some of the top common misconceptions about SAD?

Christopher Ricketts , MD: I think a lot of people sometimes feel that it's a normal part of life and much like as we get older, there are certain things where people say, oh, it's a normal part of aging. And I think that there certainly are a very large number of things that fall into that category; such as, changes in sleep pattern, bones hurting, my muscles hurt, I don't have the endurance as much as I used to.

And although there is a natural part of aging, it doesn't mean that there aren't things we can do for it. So to draw a parallel, all of us perhaps feel better when it's sunny out and it's beautiful and it's warm and we feel that freedom and flexibility to go out and just enjoy a beautiful day. It's a lot of times people feel that opposite when it's cold and windy and the nights are long and the days are short. And so I think sometimes people say, well, this is just part of being a human. This is part of normal existence. And I think there's probably an element of truth to that.

But by the same token, there also is our times where it isn't normal. And I think that the times where it isn't normal are when it really begins to affect our mood and our behavior, it affects how we feel about ourselves, it affects how we feel about other people, those around us, sometimes, I'm sure you're not alone when I say that as parents, sometimes we don't always respond in the kindest way, and I think the changes in our mood and attitude, especially during the winter months, can be a reflection of a seasonal disorder going on.

Host: Talk about how diet and nutrition impact the severity and management of SAD symptoms. 

Christopher Ricketts , MD: I actually remind people quite often that we are integrated beings. Like we are physical, we are emotional, we're spiritual, and if one of them is off, it'll have an impact on the rest of how we feel. I personally, in my practice, tend to focus more on sleep patterns than diet.

Although without a doubt diet is also touched on and it's really important. Everybody, myself included, my wife would agree that I need a lot more dark green vegetables and healthy sources of protein than we all usually get. What I find though is that often poor diet and low exercise are more a symptom than a cause for the emotional struggle.

On the flip side, one element of treatment does focus on eating better, in particular, less processed foods and getting some exercise. Often when I see people, I actually touch on brain chemistry quite a bit in my appointments, whether I'm talking about depression, anxiety, ADHD, or SAD, in particular. If people aren't familiar, I mention that there is a teeter totter like relationship between the so called stress hormone cortisol and then the hormone serotonin which is one of the main neurotransmitters involved in our mental health.

And so when we take opportunities to exercise and eat healthy, that actually can lower our cortisol levels, which then in turn, kind of like that teeter totter, as the cortisol goes down, the serotonin goes up, and that actually can have quite a positive benefit on our energy, our sense of well-being, and our mood. 

Host: As it relates to exercise, what type and duration are most beneficial, would you say? 

Christopher Ricketts , MD: In broad strokes, any exercise is better than no exercises at all. We can nitpick and say, oh, you need your X number of thousands of steps, or you need to do this number of minutes of high intensity exercise. But really, my encouragement to people is just to get up and move.

Like, whatever you can do, which is more than what you're doing, is a step in the right direction. If you are up and walking five minutes a day, hey, if we can extend that to seven and a half, that's great. You just increased by 50%, The goal is to deal with stress and low impact, but exercise that gets the heart pumping is key.

As much as we all enjoy going for that stroll when our kids are little and they're on their bikes and we take the dog for a nice casual walk. That's valuable, but some of the best exercise is that exercise that really does get your heart pumping and get the blood flowing. 

Host: You also mentioned sleep patterns. What changes in sleep patterns contribute to SAD, and then what strategies can help regulate sleep?

Christopher Ricketts , MD: Oh yeah, sleep is critical. It's numerous times a day that I ask people about their sleep and their sleep patterns. In fact, just today, numerous appointments I had already today focused on sleep. And, I just remind people that if you don't get good sleep, if you don't get that restful REM sleep, like we're all meant, that's just how our brain is wired.

Like we're just meant to get restful sleep. Like we're not going to do our best during the day. Like we're not going to be at our peak physical. We're not going to be at our peak emotionally. And so sleep is really important. There is a common concept called sleep hygiene, and sleep hygiene sometimes people just talk about, well, I need to turn my screen off an hour before I go to bed.

And that certainly is part of it. But the food we eat, minimizing caffeine, although I wish nobody smoked, you know, minimizing that nicotine exposure hours and hours before bed, even putting room darkening shades up to make the room darker can help with the melatonin burst to help us sleep. And then lastly, turning the temperature in the bedroom down a couple of degrees has been shown to be very beneficial to getting good sleep quality.

tThat said, if a loved one says that you're a restless sleeper or a loud sleeper, and I saw a gentleman for this just today, he thrashes around in bed. These can be clues to some undisclosed sleep or health disorder. And so if your partner says, hey, I've noticed this, I encourage you not blow them off, but to go talk to your healthcare provider and get it checked out. 

Host: You mentioned a partner may notice sleeping patterns. What other advice can you give to families to help them support a loved one dealing with SAD?

Christopher Ricketts , MD: One of the things that I think a lot of families struggle with is ideas of mental illness and shame. And, as you know, Cheryl, like blame is never helpful. People deal with emotional distress in lots of different ways. We all have stress, like we all have stuff.

And to be fair, some coping mechanisms that people engage in are really helpful in healing and other coping mechanisms just aren't, they can be quite destructive either to self or others. So one is just to recognize we're all human and blame is never helpful. The second piece of advice for a loved one is to remind them that their job is not to fix the person.

Like, our job as parents, as spouses, as children of parents perhaps, our job is to love them and be there and encourage them in the way that they need help. And that could be counseling, that could be medicine, that could be changes in environment or changes in relationship. Like, in other words, love them as you would want to be loved. 

Host: So there's nothing wrong with if you sense that your loved one has the symptoms for SAD to reach out and say, I've noticed this, how can I help you?

Christopher Ricketts , MD: I think many people who are in the midst of an emotional struggle on some level often recognize that things just aren't right. They may or may not be able to put their finger on it. Something that I share with patients is that, oftentimes the person in the mirror is the least able to give an accurate assessment about how you're doing. Often it's those people around us who know us best and love us are the ones that can see just little shifts in behavior, little shifts in attitude, maybe a shift in the words used to the language that really are those insights that things aren't the way they were.

And so let me, not ignore that, and let's, figure out what's going on here.

Host: Talk about wearable technology and mobile apps. Can they assist patients in monitoring and managing their SAD symptoms? 

Christopher Ricketts , MD: Here's my perspective on technology. All technology is just a tool and as such, technology needs to be kept in its proper perspective. I think that sometimes the tool itself, whether it's a, Sleep monitor, smartwatch, whatever thing that we're referring to just needs to be kept in mind that it's not the end all be all.

Certainly, I do encourage patients to, if they are worried about their sleep, there can be some useful data from wearing a smartwatch or a sleep monitor that helps them perhaps give some insight into how well they're sleeping or not sleeping. The other thing is for example, sometimes when people are down and depressed, they fall out of the habit because maybe they don't care or they feel like it's not helping as far as taking their medicines.

And so I will commonly encourage patients, hey, use your smartphone to set a reminder. And then, set that reminder that says, and I'll just tell them this, like, hey, silly, take your pill. hEy, silly, take your medicine. And then I of course remind them, hey, when that alarm goes off, don't silence it.

Don't, turn it off. Get up and do that thing, whatever it's telling you to do. As we've probably all heard, it takes about three weeks to make a new habit. And so, certainly as we try to make changes in our lives, technology can be a helpful tool to help us reach some success that we might naturally lack just if we go on our own efforts. 

Host: Now, Doctor, are there any specific risk factors that can predispose individuals to SAD that practitioners should look for? 

Christopher Ricketts , MD: Sure. And I sort of alluded to this in our introductory comments where I talked about 98 percent of seasonal affective disorder is in the colder, darker seasons. So there is a small percentage that people that do struggle with summertime seasonal disorder. And, the challenging part is you can't look forward and say, oh, in November I'm going to struggle with SAD.

It's really something that you can only diagnose either in the moment to say, it's January and how do you feel? How'd you feel last January and how'd you feel the January before that? Oftentimes it's that retrospective information, that retrospective look at life that says, you know what?

Yeah, I guess, I was struggling with this last year and maybe not the year before. And I think maybe the year before that. So sometimes just getting a pattern over time is helpful. The second way that I would help answer this, Cheryl, is just to recognize that genetics can play a role.

We know that for all sorts of diseases and mental illness isn't exempt from this, that there is a large genetic component. Now, genetics aren't determinative, and what I mean by that is just because a disease or a challenge or a particular tendency runs in a family, that's not a guarantee that it will 100 percent show up and not necessarily either be the explanation for a person's symptoms.

To draw a different example, coronary disease, heart disease might run in someone's family, but that doesn't necessarily mean that, that person's chest pain is a heart attack. I think the same awareness also exists for SAD that just because something runs in the family, it might make it possible that that's what's going on, but it's not a guarantee. 

Host: What are the latest findings in the connection between vitamin D levels and SAD?

Christopher Ricketts , MD: I love vitamin D. I think it's really a remarkable vitamin that has been come into the public awareness in the past decade or so. I know many will say well, we've known and we've treated vitamin D for for eons and eons, which is true I think in the naturalist community. Like they really deserve a lot of credit for focusing on vitamin D well before a lot of mainstream medicine doctors began to start actively checking vitamin D levels. So as far as a look back to some brain chemistry, vitamin D actually does help the production of serotonin in the brain and peripherally, so outside the brain, it helps decrease the destruction of serotonin.

So on the one hand, it helps your body make more serotonin and on the other hand, it helps your body not get rid of it as quickly. So vitamin D levels, absolutely, they're a critical part of helping maintain normal serotonin levels. Is vitamin D everything? No, but it's really an important part. In terms of blood work, your doctor can order vitamin D levels. We'd like to see levels above 30 and often that is about where on the low end we need them to be to have relatively normal serotonin production. I often also get a question about K2, so vitamin K2, and sometimes people will see on the vitamin bottle, vitamin D3 with vitamin K2, it's something where K2 does help vitamin D absorption and metabolism, however, it is also not innocuous. 

In other words, there is risk with vitamin K2. So before a patient automatically just starts taking vitamin D with K2, I do recommend you check with your healthcare provider to make sure that you aren't someone who shouldn't be on this particular supplement. 

Cheryl Martin (Host): Are there ways environmental modifications to your home or office can help alleviate SAD symptoms? 

Christopher Ricketts , MD: I am a big fan of lifestyle changes before medicine. I've certainly prescribed tons of medicine, but at the same time, as I tell people, like another phrase that I use with people is that it's easy to take a pill. It's hard to make a change. And so oftentimes if we can change some aspects of our environment, that can often lead to a significant improvement in alleviating SAD symptoms. You and I both already talked about exercise. We talked about sleep hygiene. We talked about diet, vitamin D, K2, like we've really covered some nice territory today. In addition, one of the things that I'm also a big fan of is what is called light box therapy. And so, it's just like it sounds.

There's this little box that has really bright lights of a particular wavelength. And, often what people will do is they will shine this bright light basically right in their face for about 20 to 30 minutes. The morning time is best because that's often when we need to get that serotonin burst to help us get our mood in a good place.

I find that a lot of people are able to add lightbox therapy during the darker days of wintertime, and that either allows them to not need to take any prescription medicine, or it allows them to not need to increase their medicine during the times they struggle with the SAD, and then the flip side, when gets beautiful out and they're able to get outside, they often don't need the lightbox therapy quite as much as during the wintertime months. 

I don't have a particular brand or anything like that to recommend just because as I tell people, there's just hundreds if not thousands of options out there. And so I just recommend that they do a little searching to find the one that seems to fit them the best. The other thing that I also remind patients of is if they have, say, a health savings account and they're looking for something to spend it on, this, is certainly be a very appropriate health expenditure that should be covered by their HSA. 

Host: Dr. Christopher Ricketts, thank you for educating us on seasonal affective disorder and ways to beat the winter blues. Thank you. We covered a lot of ground. 

Christopher Ricketts , MD: Cheryl, I really appreciate the opportunity to spend time with you today. Thank you for asking. 

Host: To find out more information about Dr. Ricketts, just visit our website at woodlawnhealth.org. If you found this podcast helpful, please share it on your social media and thanks for listening to Woodlawn Health DocTalk, a podcast from Woodlawn Hospital.