Case study: Spring has finally arrived in your town. Days are longer, and the pollen count is up. You are hoping to leave clinic a little earlier than usual so you can go take a walk in the warm sunshine, but then your hopes are dashed when you realize that your last patient will likely be a long appointment. Janie is a 39-year-old woman who is generally in good physical health but has been coming to clinic frequently these past few months with headaches, abdominal pain, and skin breakouts. After she left your clinic a few weeks ago, you wondered if her complaints were, at least in part, psychosomatic. With a sigh, you open the door to the examination room.
To your surprise, Janie looks cheerful today. Instead of her typical monotone, her voice is engaging. She tells you that she is here because her seasonal allergies are acting up from the pollen and she would like recommendations for sinus relief. However, you want to know about the change in her affect. What do you ask Janie?
While performing the physical exam, you ask Janie how things are going in her life. She shrugs her shoulders and says things are going well. So, you persist and ask her about her mood. At this point, she tells you that she had a miserable winter, but she always feels better when spring arrives. On physical exam, her vital signs and exam are completely normal except for some bogginess in her nasal passages consistent with allergies. That’s when it occurs to you that perhaps Janie has Seasonal Affective Disorder (SAD).
Seasonal Affective Disorder is a mood disorder that affects approximately 5% of people in the United States per year. It is more common in Northern climates, among people with a history of depression, and in people with a first-degree relative who suffers from depression. In order to diagnose it, clinicians use the DSM criteria for SAD. Although these criteria are similar to the criteria for depression, they also ask questions about recurrence and seasonality – which you have already noticed in this patient. What do you do next?
You ask Janie if she has a history of becoming depressed in the fall and winter and feeling better in the spring and summer. Surprised, she says that yes, she has felt this way for years. In fact, she always thought that everyone felt this way. You say that you suspect she might have Seasonal Affective Disorder, and tell her a little about the disease. Since she is doing well right now, you decide to wait until closer to fall to start her on antidepressants. For now, you discuss the possibility of her starting cognitive behavioral therapy tailored to treat SAD. You also recommend that she buy a light box and have it ready for when the days become shorter in the fall. Finally, many patients with SAD find that taking antidepressants, particularly SSRIs, in the fall and winter months is helpful until the changing seasons and increasing light lift their moods up again.
How do you manage your patients with SAD? Comment below.
For more information:
Kurlansik SL, Ibay AD. Seasonal affective disorder. Am Fam Physician. 2012;86(11):1037-41.
National Institute of Mental Health (2016). Seasonal Affective Disorder. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml
Dr. V. Silverstein
Published on 5/1/18