It was early November and, as in years past, my client Bruce called for an appointment. His depression was spiraling downwards toward suicidal thoughts. Additionally, he was sleeping more than twelve hours a day; his concentration had become so fuzzy that he was forgetting to take his HIV medications; and he reported that his neuropathic pain was "worse than ever." He had seen me for psychotherapy intermittently for the past three years, always calling for an appointment in late fall, and every year experiencing a resolution of his symptoms in the spring.
Although I practice in Florida where winter months are sunnier and have more hours of daylight, it was clear that Bruce had seasonal fluctuations in mood, and he is not alone. Some individuals are more sensitive to changes in daylight hours no matter where they reside. Bruce was experiencing "winter depression," sometimes called Seasonal Affective Disorder (SAD). SAD is not a distinct disorder but rather a variant of depression. It typically begins with increased depression in the autumn (a small minority of people have more symptoms in summer) and can reverse into mania in the spring and summer. In recent years, researchers have questioned whether it actually exists, although findings are complicated by inconsistencies in measuring symptoms and the power of suggestion of a phrase such as "seasonal blues." While the classification of SAD might be in flux, many people living with HIV/AIDS experience a worsening of symptoms in the winter months that is worthy of attention.
One critical reason for heightened vigilance is that people living with HIV are already at a significantly greater risk for mood disorders. The American Psychiatric Association reports that over 15% of people living with HIV experience general anxiety disorder. Studies have found that nearly half meet criteria for depression and have suicide rates three times that of the general population. Any disorder that negatively impacts mental health, quality of life and event lethality among an at-risk population such as people living with HIV must be carefully followed.
What Are the Symptoms of SAD?
Seasonal Affective Disorder can involve almost any symptom associated with depression: low mood; loss of interest in activities; low energy; oversleeping; difficulty concentrating; feelings of hopelessness, worthlessness and guilt; and increased thoughts of death and suicide. Symptoms are typically mild in the fall and worsen as the season continues. SAD is caused by the seasonal drop daylight hours that disrupts circadian rhythms, causes a drop in the mood-regulating neurotransmitter serotonin and disrupts the balance of melatonin. Higher risk populations for SAD include being female, living farther from the equator, having a family history of the disorder, being younger and having co-occurring depression or bipolar disorder.
How Does SAD Affect People Living With HIV?
A number of factors potentially complicate the impact of SAD. Colder weather can increase isolation and aggravate chronic pain, both of which can contribute to a darkening of mood. Many people living with HIV have unhappy associations with the holidays and, indeed, experience far greater levels of stress around family, celebrations and the cultural expectations of the season. Changes in routine, either as an adaptation to weather or for the holidays, can contribute to a sense of being less grounded and engaged within support systems. Decreased levels of concentration further aggravate changes in routine and can lead to poor medication adherence or self-soothing through substance misuse or high-risk behaviors.
What Treatments Are Available for SAD?
Several effective treatments for Seasonal Affective Disorder order are available. Someone experiencing symptoms of SAD might benefit from one or a combination of therapies:
- Phototherapy: This consists of sitting in front of a light box for 20 to 60 minutes per day in the winter months. The therapeutic value comes from the brightness of the light (typically 10,000 lux), not necessarily full spectrum light. Most lightbox manufacturers filter out UV light because of its potential harmful effects. Users typically sit in front of the box in the morning with eyes open while avoiding looking directly at the light. Consultation with a mental health provider is advised because, in some cases, too much light too soon can actually trigger a manic episode.
- Psychotherapy: Cognitive behavioral therapy (CBT), a form of talk therapy that takes a practical, problem-solving approach to changing thoughts and behavior, has been shown to reduce symptoms of SAD after eight to ten weeks. Therapeutic gains made through CBT can persist longer than those achieved with medication (see below). If someone has not had relief with CBT after twelve weeks, they should be considered a candidate for medication, keeping in mind that the most therapeutic benefit often comes from a combination of talk therapy and medication.
- Medication: A common family of antidepressant medications known as SSRIs (selective serotonin reuptake inhibitors), along with another antidepressant called bupropion (Wellbutrin), has shown efficacy at reducing the symptoms of SAD. These are generally well tolerated with HIV medications, and many non-psychiatric practitioners are comfortable prescribing them. If there is significant mood disturbance, however, it is always important to have a consultation with a mental health professional. In addition to these antidepressants, vitamin D is said to mitigate the symptoms of SAD, although scientific studies attempting to document its effects have been inconclusive.
People living with HIV/AIDS need to be protective of their mental health. Rates of depression and anxiety, even among those with undetectable viral loads and higher T-cell counts, remain at significant levels that not only carry a risk of suicide but also threaten overall quality of life. Whether we call it SAD, seasonal blues or winter depression, a reduction in overall hours of daylight is a risk factor that can seriously impact the well-being of some people living with HIV, and one that is worthy of our attention.