Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons

By Norman E. Rosenthal M.D.

Dr. Norman Rosenthal, is the author of the bestselling Poetry Rx released last year to rave reviews including:

• NY Times The Well Book List of 8 Favorite Books in 2021 for Healthy Living
• And The subject of a NY Times op ed by Jane Brody

Now in his landmark new book, Defeating SAD, Rosenthal, who first described Seasonal Affective Disorder (SAD) and is the foremost authority on the subject, offers an up to date guide to overcoming the miseries and that millions experience with the changing seasons. In his lively style, Rosenthal offers advice on how to identify, treat and overcome both winter and summer varieties of seasonal affective disorder, as well as the less severe yet bothersome winter blues.

Having pioneered the use of bright light therapy for SAD and relying on his decades of experience treating SAD patients Rosenthal offers strategies and techniques for defeating the condition, including cognitive-behavioral approaches, diet and exercise advice, medication and meditation.

Rosenthal’s warm and friendly professional style will leave the reader feeling as though he has been treated to a consultation with a consummate professional, who has fascinating insights into the condition. The book will help show how to optimize your health and well-being through the seasons.

• Language: English
• Publisher: G&D Media
• Release date: Aug 15, 2023
• ISBN: 9781722527624

Norman E. Rosenthal M.D.

Norman E. Rosenthal is the world renowned psychiatrist, researcher, and best-selling author, who first described seasonal affective disorder (SAD) and pioneered the use of light therapy as a treatment during his twenty years at the National Institute of Mental Health. A prolific researcher and author, he has authored or co-authored over three hundred scholarly articles and ten popular books. These include Winter Blues, Poetry Rx, the New York Times bestseller Transcendence and the national bestsellers, The Gift of Adversity and Super Mind.

Book preview

Cover: Defeating Sad, Seasonal Affective Disorder, A Guide to Health and Happiness Through all Seasons by Norman Rosenthal

DEFEATING

SAD

{SEASONAL AFFECTIVE DISORDER}

A GUIDE TO

HEALTH AND HAPPINESS

THROUGH ALL SEASONS

NORMAN E. ROSENTHAL, M.D.

Logo: G&D Media

Published 2023 by Gildan Media LLC

aka G&D Media

www.GandDmedia.com

DEFEATING SAD. Copyright © 2023 by Norman E. Rosenthal

No part of this book may be used, reproduced or transmitted in any manner whatsoever, by any means (electronic, photocopying, recording, or otherwise), without the prior written permission of the author, except in the case of brief quotations embodied in critical articles and reviews. No liability is assumed with respect to the use of the information contained within. Although every precaution has been taken, the author and publisher assume no liability for errors or omissions. Neither is any liability assumed for damages resulting from the use of the information contained herein.

First Edition: 2023

Interior design by Meghan Day Healey of Story Horse, LLC.

Library of Congress Cataloging-in-Publication Data is available upon request

eISBN: 978-1-7225-2762-4

10 9 8 7 6 5 4 3 2 1

CONTENTS

Introduction

1 What Is SAD?

2 What Are the Winter Blues?

3 Seasonality and the Seasonal Pattern Assessment Questionnaire (SPAQ)

4 Causes of SAD and the Winter Blues: A Three-Legged Stool

5 How Common Are SAD and the Winter Blues?

6 Where Do I Begin? The Big Picture

7 Light Therapy for SAD

8 Answers to Questions About Light Therapy

9 Cognitive Behavioral Therapy for SAD

10 The Positive Side of Negative Ions and Vice Versa

11 Spring Fever

12 Summer SAD

13 Autumn Check-Up

14 Foundational Habits I: Eating, Weight Management, and SAD

15 Foundational Habits II: Exercise, Sleep, and Meditation

16 Escapes and Diversions

17 Medications for SAD

18 Other Benefits of Light Therapy

19 The Science of SAD and Light Therapy

20 Life after SAD

Acknowledgments

Notes

Index

Introduction

In the midst of winter, I found there was, within me, an invincible summer. And that makes me happy. For it says that no matter how hard the world pushes against me, within me, there’s something stronger—something better, pushing right back.

—ALBERT CAMUS

I arrived home one evening to find my voicemail unexpectedly full and wondered, What on earth could be going on?

When I clicked the replay button, I heard the familiar voice of my trainer, much more excited than usual: Hey, Doc! he said, "You finally made it. You were part of a clue on Jeopardy!" The other messages were variations on the theme. Apparently more people watch Jeopardy than I had realized. The answer to the clue was, What is Seasonal Affective Disorder?

My mind flashed back to the early days of my SAD story, where I sat in my office, surrounded by completed questionnaires. One after the other, people wrote about their struggles with the autumn and winter in tones so sorrowful and touching as to leave no doubt that they were experiencing a recurring state of depression and disability year after year. I was impressed not only by the seriousness of their responses but by their monotony. Our understanding of mood disorders has been bedeviled by variability across individuals, so this sameness was exciting in suggesting a unifying underlying biology that might yield new answers to old questions.

Let me explain how I came to be surrounded by these questionnaires in the first place. I arrived in the United States from South Africa in the mid-1970s, and after doing my psychiatric residency in New York City moved to the National Institute of Mental Health (NIMH) to join an innovative psychiatric research group. There, my colleagues, under the leadership of Fred Goodwin and Tom Wehr, were studying circadian rhythms in psychiatry. Another colleague, Alfred J. Lewy, spearheaded the work that first showed that nighttime secretion of melatonin in humans could be suppressed by bright light.¹

This was an important finding, since it showed that light—specifically bright light—could influence biological functions in humans beyond enabling us to see. Since the publication of Lewy’s landmark paper, we have come to realize that bright light can affect many nonvisual functions in humans, including mood, rest and activity, and circadian rhythms. Melatonin, a hormone secreted by the pineal gland, had been recognized as important in orchestrating seasonal rhythms in nonhuman animals. The finding by Lewy and colleagues opened up the possibility that humans might not be an exception in this regard.

Into this bubbling cauldron of ideas stepped a spry middle-aged engineer named Herb Kern, who had observed seasonal patterns of depression in himself. As the days got shorter, he felt depressed and could barely do his work. That changed when the days began to lengthen and, in his words, the wheels of my mind began to spin again. Being an engineer, unencumbered by the traditional psychiatric theories of the day, Herb was convinced his problem had something to do with the changing light.²

Herb’s story resonated with me. I had also felt low and slow in the dark months of winter, as did my wife. This had never happened in South Africa, which made me suspect that Herb Kern was on to something.

Al, Tom, and I exposed Herb to bright environmental light in the morning and evening during one of his depressions, and presto! He emerged in fine spirits.³ Since a single successful outcome is not necessarily replicable, I realized that we needed more people with winter depression so as to study light therapy using the time-honored techniques that are critical for testing medical and psychiatric treatments: randomized controlled studies.

With the help of a Washington Post reporter, I publicized our early clinical experience and invited others with similar stories to contact us.⁴ I expected to find perhaps only a handful of such people, as several experienced local psychiatrists whom I had informally surveyed claimed never to have seen such a case.

Imagine my astonishment when the article was syndicated across the country, and thousands of people endorsed the symptoms of what we now know as SAD. It turns out that SAD is a common condition that was overlooked perhaps because it was so common that people might have thought, That’s just the way people feel in winter.

Trusting the accuracy of the reports of those who responded to our article, we followed a group of people from the summer, when they were well, into the fall and winter, with the expectation that they would develop the symptoms they had reported. Won’t you feel foolish, one of my colleagues asked, if they don’t become depressed? Strangely, I was not concerned about that, perhaps because I had personally experienced seasonal ups and downs and believed that my patients would become depressed as predicted—and they did.

My colleagues and I enrolled this group into a randomized controlled study of bright light therapy (BLT), which became the basis for the 1984 paper in which we first described SAD and its response to BLT.⁵ (I am aware that this abbreviation may remind you of a lunch sandwich, but since it is popular in the literature, I will be using it interchangeably with light therapy in the hope that the gastronomic association will fade.)

In the forty-plus years since I first began to work on SAD, I have treated thousands of patients with the condition. I know that thousands, if not millions, more are suffering from it. Some of you have reached out to me over the years. I regret that I have not been able to respond to all individually, but I hope this book will be a source of comfort, solid information, and practical advice to those I have not been able to see in person.

In framing my goals for the book, I am reminded of one of my SAD patients, a medical colleague (I’ll call him Alister) who came to the D.C. area from the sunny West Coast many years ago. In his first winter here, he developed a severe case of SAD, a condition that would remit each spring and return with a vengeance each autumn. He found it difficult to get to work in the morning, struggled to be present for his family, and lost his libido and his interest in the hobbies and activities that had previously been a source of daily joy.

I treated Alister over the years with all the strategies that I will describe in this book. Each winter was better than the one before, and he improved to such an extent that he needed to visit me only once a year. At each annual visit, he told me I had taught him a new technique for how to do better the following year.

Finally he stopped coming to see me. I felt no reason to call him and find out why. I suspected the answer he would give me: I had taught him all that I knew, and he no longer needed my help.

But I was wrong. Alister recently contacted me again. He and his family were finally in a position to return to California, and he wanted to know what to consider in making that decision. I told him that, unsurprisingly, people with severe SAD tend to do better in Southern California than in the San Francisco area, which he and his wife favored. Luckily people had written to me about their problems with microenvironments in San Francisco, where some people might enjoy a home on an elevation with glorious sun exposure while others languish in relative darkness because of perennial shadow or cloud cover. And so it is that whenever people consult me, I dip into my pool of memory and experience and see what I can pull out that may be of help to them.

My hope for this book is to teach you all that I have gleaned over the forty-plus years since I sat in my office reading through the questionnaires from which I first assembled the elements of the condition that we now know as seasonal affective disorder or SAD. If SAD is a new concept for you, I hope this book will offer you a feast of information (sprinkled with some helpful stories) as I share with you the adventure of the past four decades. Even if you already are something of an expert in managing your symptoms, perhaps you will find in these pages some new perspective or stratagem that will help you get through your difficult season.

Defeating SAD versus Winter Blues

In the early 1990s, I wrote a book Winter Blues, focusing on the problem of SAD and describing light therapy as the basic solution. Since then enough has changed to warrant an entirely new way of looking at SAD and its treatment.

Here are my reasons and goals for writing Defeating SAD, which reflects a shift in my emphasis from the problem to the solution.

As the title Defeating SAD suggests, this book explores not just how to cope with SAD, but how to soundly defeat it. This new version provides a more solution-oriented approach for defeating SAD, supplemented by new research findings and decades of clinical experience. In this new book, I will offer the most up-to-date information and useful advice, while retaining what was helpful about my earlier book.

People have changed how they read since the earlier book was written. We are now more impatient for the author to get to the point and give us the bottom line without discursive case histories. We want our information presented to us in a new, more concise way.

I have tried to respect these new preferences, although, being a storyteller at heart, I can’t resist the occasional vignette as long as it is instructive and interesting. Some of you may recognize a few characters or scenarios mentioned previously in Winter Blues. They were just too colorful to leave behind.

In my earlier writing, I was dazzled by the tremendous promise that light therapy offers those of us who suffer from SAD and related conditions. My excitement at that promise remains undimmed. Since then, however, I have become increasingly convinced that there is so much more we can do in conjunction with light therapy to defeat SAD (and other emotional problems as well).

The main therapeutic goals of this book are:

To present my experience with SAD and light therapy in an accessible way.

To offer a holistic approach that will maximize your well-being and enjoyment of life through all seasons. Specifically, I show how you can obtain the best results by combining light treatment with other specific forms of therapy and lifestyle changes.

You will see that I have italicized the words combine and combining throughout the book to remind you that the sum of different approaches is usually better than any one approach alone.

To offer you a concrete example, let’s say light therapy reduces your symptoms by 50 percent, adding exercise may raise that number to 60 percent, and then adding cognitive behavior therapy a further 20 percent—to 80 percent. Consider it a challenge to keep upping your game, and soon you may not feel any SAD symptoms at all.

1

What Is SAD?

Seasonal Affective Disorder (SAD) is a condition of regular depressions that occur in the fall and winter and typically remit in the spring and summer.

That, at any rate, is how we defined the condition when we first described it. Since then it has become clear that nature often doesn’t adhere to precise definitions. Sometimes people get excessively exuberant in the summer—a condition called hypomania. They may even become overactivated to the point of having racing thoughts, talking too much, and showing bad judgment, which can run them into trouble. We’ll talk about these variations later. For now let’s consider some of the classic features of SAD.

Common Symptoms of SAD

Feeling slowed down in thinking and action

Sadness

Worry or anxiety

Disengagement and lack of interest in life

Increased appetite

Craving for sweets and starches

Greater need for sleep

Less interest in sex

Effects of These Symptoms

Difficulties at work and in interpersonal relationships

Feeling that people don’t like you or are ignoring you

Falling behind with chores

Feeling worse about yourself because you are not being as productive, sociable, or successful as you usually are

Other Troublesome Consequences

Life loses its sense of sparkle and luster.

Self-esteem suffers as you tell yourself: I used to be able to do so much before. Why am I having so much difficulty now?

You chastise yourself for underperforming, often reinforced by feedback from others.

In severe instances, life may not feel worth living, and suicide may cross your mind. Although this is fortunately rare in people with SAD, it is very important that such ideas always be taken seriously and shared with a professional and those who care about you.

What Happens to People with SAD in the Summer?

People with SAD typically experience one of three mood states in the summer: Euthymia (normal mood), Mania, and Hypomania.

Euthymia (normal mood)

Happy that winter is passed, you can feel like your summer self again—your best self. Every day is enjoyable, and there might even be an exuberance that others may find charming.

Mania

Full-blown mania is rare in people with SAD. I am referring here to a period of greatly increased energy and activity that may be exhausting to manic people as well as to those around them. In mania, people experience flight of ideas, speak rapidly, and sometimes