Dr. Norman E. Rosenthal doesn't take any chances.
Every fall, as daylight diminishes, the psychiatrist begins his wintertime attack against seasonal affective disorder. He doesn't want to feel lethargic, to overeat, to crave carbohydrates, to feel dull and uninterested in life, to be irritable and moody -- all symptoms of SAD.
So, at 4 a.m., a dawn simulator that mimics the sunrise turns on the bedside lamp in his Bethesda, Md., home, admitting light through his closed eyelids. By 5:30 a.m., with that lamp at maximum intensity, a light box turns on, exposing Rosenthal's eyes to more light. Three or four days a week, Rosenthal walks outdoors or works out at a gym. Sometimes he eats breakfast in front of a 10,000 lux light box, and he also uses one at his desk.
"I just move from one lighted space to another, attempting to replicate summer light," said Rosenthal, clinical professor of psychiatry at Georgetown Medical School and author of "Winter Blues," which he wrote in 1993 and updated five years later.
In the book, Rosenthal said he's not even sure he's still susceptible to SAD since he takes so many precautions against it.
Typically, young people and women are at highest risk for seasonal affective disorder, though the National Mental Health Association says it can affect anyone. SAD may begin at any age, even in childhood, but the main time of onset is between 18 and 30 years, Rosenthal said.
Stress appears to be a trigger, and there are indications that SAD may be inherited. Also, because the amount of light entering the eyes is a factor, anyone who has developed cataracts may be more vulnerable, according to Rosenthal.
In fact, an estimated 25 percent of the population experiences a mild form, and about 5 percent suffer more severely.
One more thing: SAD is more prevalent in sun-starved regions. For example, while almost 10 percent of New Hampshire residents are affected, only 1.5 percent of people in Sarasota, Fla., get SAD, according to a study Rosenthal authored.
The best cure, therefore, is to move to within 30 degrees of the equator -- Southern Spain or Africa, for example.
Or, as Rosenthal instructs his patients: Get more light. Think of the way a cat follows slivers of sunlight for naps throughout the day.
If you can't move to the sun, plan winter vacations in Florida or Arizona. Get up at a reasonable hour to capitalize on the amount of daylight. Walk outdoors frequently, the earlier the better. An hour's walk in winter sunlight is as effective as two and a half hours under bright artificial light, according to the National Mental Health Association. Add more lighting to your house. Replace dark carpeting, lighten wall colors. Sit near a window. Don't wear dark sunglasses, which give a double dose of darkness. Consider using a light box.
'This is an illness'
Seasonal affective disorder isn't imaginary or psychosomatic, experts say. Though there are countless references to this seasonal malaise in literature, poetry and medical reports, it wasn't studied systematically until Rosenthal and colleagues at the National Institutes of Mental Health described the pattern in 1984.
It has since become officially recognized as a disorder by the American Psychiatric Association.
To be considered seasonally affected, sufferers have to experience symptoms that begin in the fall or winter and remit in the spring, with episodes occurring at least two years in a row, said Dr. Jeffery Grace, clinical director of the Buffalo Psychiatric Center.
While these winter blues can hang on, like Western New York's gray days that seem to last from September through April, the worst months are December, January and February.
"Don't set a March 1 deadline for a big project," advises Rosenthal.
Grace suggests staying actively engaged in life, seeing friends, exercising and eating properly, as well as reading uplifting novels and watching entertaining videos.
"You can reframe how you are living," said Grace, a board member of the local Mental Health Association.
He also recommends envisioning a picture perfect -- and, obviously, sunny day -- much the way an athlete visualizes strategies for competing.
His visualization is of a trip he took to Yellowstone National Park during the winter. "It was freezing cold, but that made everything bright and glittery," said Grace. "You don't have to actually go to a place, you can just think about it. It's as effective as being there."
If, however, the disorder slides into full-blown depression, don't delay in seeking help, Grace said. "One out of four Americans, at some time during their life, will experience depression that could benefit from support," he said.
"There is an old adage that you can work yourself out of it, but that's not true. This is an illness, just like diabetes or heart disease."
And it can be effectively treated, Grace said, with the anti- depressants that are available or with psychotherapy or counseling.
Bathing in light
The exact cause of seasonal affective disorder remains somewhat shrouded in darkness, though researchers link it to a lowered level of serotonin, the brain's feel-good chemical; and to an increased level of melatonin, a sleep-related hormone secreted by the pineal gland in the brain. Melatonin, believed to cause symptoms of depression, is produced at greater levels in the dark, so that when the days get darker, the production of this hormone increases.
And that's where light therapy comes in, as a way to trick the brain into thinking that it's getting more sunlight.
The most intense way is to do it with light boxes. While the average home or office lighting delivers an intensity of 200 to 500 lux, the minimum dose necessary to treat SAD is 2,500 lux, and some lighting units provide 10,000 lux (therapy recommendations are within that range). Users typically sit in front of a light box from 30 minutes to two hours daily.
Rosenthal said that patients often ask him if it's better to have a larger or a smaller unit, which is more portable.
"The smaller ones probably aren't as effective because you aren't bathing as much of your eye in the light," he said. "If you are using a small box and moving your head from side to side, you'd be surprised how much light you miss with the smallest divergences of the head."
Rosenthal said while anyone suffering severe depression needs medical treatment, a person who has a less severe form of SAD could experiment with light therapy to see if it provides relief.
"If it's a clear seasonal pattern and someone is a bit down in the dumps, I don't think that they always have to involve a doctor from the get-go," he said.
Mild side effects have been reported by some people using light therapy, including headache, eye strain, skin irritation and "feeling wired." Generally, the side effects can be resolved by gradually increasing the amount of time in front of the light box.
People who have eye or skin conditions are advised not to use light therapy. Also, some medications can cause light sensitivity.
Rosenthal said he has learned that it's important to start treatment before symptoms start. Though he has spent many years studying SAD professionally and treating people who have it, Rosenthal said it has taken him a long time to come up with effective personal strategies to beat the winter blues.
"Everyone is different," he said. "It has taken me some time to learn all the tricks to make life easier during the difficult winter months."
e-mail: pvoell@buffnews.com
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