Fall Warning

Fall WarningNorthern Hemisphere Fall Warning

If you live in the northern hemisphere, and particularly if you live in the United States, this seems like an appropriate time to point out that fall is coming.  The yellow school buses are once again trundling through the streets taking kids to school, the commute has once again jumped up by a factor of two in the Bay Area, and it is definitely getting light quite a bit later in the morning.  For most people, it’s not yet time to start experiencing significant seasonal mood symptoms, but it is a good time to prepare for the change in seasons.  I encourage those who tend toward depression to purchase a therapy mood light.  You can find links to articles on this topic here.

It’s also a good time to be thinking about how you will remain active with shorter days and less sunny weather.

  • Should you sign up for a gym membership?
  • Have you been thinking about buying an elliptical trainer or a treadmill?

This a good time to come up with a plan.

Don’t wait to figure this out when you start noticing your mood change with the season, by that time you may be feeling too lethargic to act.

Finally it’s worth recalling that this is also an anniversary of a sort for people who have graduated from college in the last few years.  You might notice feelings of discontent as you reflect on your life now and compare it to when you were in school. Goals and responsibilities are much clearer in college than out in the real world.

Spring into Summer: Light and Sleep Changes

lightMany people have been noticing the very long days of late Spring and early Summer.

There is more energy to get things done, although that energy can end up being challenged into anxiety and irritability if you aren’t careful and don’t get at least a few hours of sleep every night…

I often think about my trips to Alaska a few years back. And stories of friends going backpacking and never really sleeping for days on end.

There’s something so seductive about staying up late. Many people are reminded of their childhood and the fun and adventure of a late night party or sleepover. There is a pleasant thrill from doing something that is usually not allowed.

The sunlight makes it possible to go without sleep for longer than is usually possible. But there are limits, and those friends found themselves getting more and more foggy and confused and almost not making it back to the trail head.

Elsewhere I have written about new research that shows that sleep is the time when our brain gets rid of toxic chemicals that build up during the day. A biochemical explanation for the loss of mental acuity that comes from too many nights without enough sleep…

This is a good time to put a little extra energy into preparing for sleep. Make a conscious effort to turn off the screens (with the sun up so long you don’t really need to be watching TV and using your computers late. Go for a walk at dusk and your brain and body will naturally wind down and prepare for sleep. The cooler air of evening will help, too.

If you’re experiencing increased energy from longer days, make sure to be somewhat thoughtrful about how you use that energy. It’s a very good time to get healthier. Increased exercise and a healthier diet are ways that you can use the energy now how to build reserves of energy for the fall and winter.

 

How Light Affects the Brain

lightTwo recent articles that I reviewed highlight the accumulating evidence that something as simple as sunlight has profound impacts on brain biology.

When I suggest to people that they pay attention to daily light exposure and, particularly, to getting bright light for 45 minutes every morning, I am often looked at with skepticism. “Sure doc,” I hear the other person thinking, “If you say so, but I want to talk about things that really can change my mood for the better… I want to talk about medications…”

Steven Dubovsky reviewed an article in Nature Neuroscience that demonstrate that light exposure changes the activity of genes in the brain (Azzi A et al., Nat Neurosci 2014 Mar 17:377). The authors of the study found that there were major changes in the brains of rats exposed to daily morning light, compared with rats that did not have the regular experience of daily light. They also showed that this widespread alteration in genes in the brain, could be normalized with a week or so of regular light exposure.

Other authors have shown (Fisher PM et al., Biol Psychiatry 2013 Dec 19) that one of the (perhaps surprising) effects of not having light exposure is of increased activation of the amygdala (the part of the brain that reacts to threats and creates the emotion of fear). Animals without normal light cycles tended to misinterpret normal events in the environment as threats. This might help explain why disrupted circadian (daily) rhythms can be associated with depression.

Remember when your mother said, “take your vitamins?” It turns out that daily light might be even more important for good mental and physical health

The Evils of the Snooze Button – Why Sleeping In Makes You Feel Tired

snooze buttonWinter is the time of year that the snooze button on your alarm clock can wreck havoc with your mood. Just as waking up early and getting light and exercise is the fastest way to improve depression, trying to sleep in, or lying in bed thinking about why you don’t want to get up, is the best way to make you feel worse.

Of course, it doesn’t seem that way when you are in bed and your brain tells you – “you are tired, you need more sleep,” but in fact that poor quality sleep is going to make you feel more tired, not less.

Over the years we have learned the hard way that feeling tired is much more strongly correlated with sleeping too much than with not sleeping enough. In fact people can do pretty well on 6 and a half or 7 hours of sleep a night (that may not be ideal, but it is much better than 8 and half or 9 hours of sleep).

What some of us need is an alarm clock that won’t take “no” for an answer. This is why we occasionally tell one of the people we are working with that they might want to consider buying Clocky – an alarm clock that runs away from you if you are sleeping too long and won’t let you turn it off.

As an alternative, before you go to sleep get your clothes out, and visualize getting up and putting on clothes, or sweat pants, or getting a cup of coffee without thinking about whether to do it or not. That should help you get up and out of bed.

Using a Therapy Light

12-26-2013 8-36-53 AMChristmas vacation is ending, It has been wonderful to spend some relaxing time with family, getting up later in the day, lounging around and playing games, reading, or watching TV… and eating too much good food.

Now the challenge is getting back to a more productive schedule. For many of us, our bodies are in a “hibernating” mode that makes it hard to wake up in the morning.

Think of a bear and you will get the picture. Bears, during the winter, don’t actually sleep all the time, rather they enter a twilight zone where they alternate, almost at random, between a lethargic, half asleep, waking state, and a very light, half awake, sleeping state. 12-26-2013 8-30-30 AM

What happens that makes this possible is that the bear’s internal clocks, their biorhythms, are all out of sync with each other, and out of sync with the outside world.

If we lived back in the past, when there weren’t the crazy demands of modern life, many of us would be naturally, and perhaps pleasantly, semi-hibernating all winter.

But we don’t.

The solution to this problem is to use a therapy light to resynchronize our body clocks. Bright light in the morning is what “sets” our clocks every morning, and the reason that we enter semi-hibernation is because there is very little bright light in the winter… especially if we work indoors and drive to work (usual indoor light is not bright enough to synchronize our body clocks).

There are two types of therapy lights: full spectrum lights and blue spectrum lights.

Blue spectrum lights make use of the fact that it is the blue end of the light spectrum that is mostly responsible for setting our body clocks. The result is that blue spectrum lights can be smaller and put out less total light, because 12-26-2013 8-33-06 AMthey just emit the “active” part of the spectrum. You can, for example, buy one that runs on a battery and can therefore be taken with you on business trips or vacations. The trouble with blue spectrum lights is that they have a theoretical potential for causing eye damage, especially if you have blue eyes (which are more sensitive to light). I say theoretical because, whereas it is clear that ultraviolet light can hurt your eyes, it is not clear that blue light can do so. And if it does hurt your eyes, it is much less of a problem than going outdoors in the sun without sunglasses…

Full spectrum lights serve two purposes. They sync your body clocks and they help you see things better. Full 12-26-2013 8-20-48 AMspectrum light is the ideal light for doing things that require good vision – reading, knitting, etcetera. I particularly like full spectrum floor lamps, because one of the most common problems with people who use therapy lights is that the light is not close enough to their eyes, often because it is on a table that is already a couple of feet below eye level. The BlueMax lights are compact and reliable and I have several of them for personal use (at home, and in two of my offices). You can see one being used as a sewing light in the picture at the right.

OK, now that you have a light, what do you do with it?

My usual prescription is 45 minutes of bright light (10,000 lux of full spectrum light) every morning before 9 am.

The key is that the light has to be set up so that it is no more than one and a half feet from your eyes. This may require some creative use of stands, if you haven’t bought a floor lamp. The fact that it is awkward to set up a light is illustrated by the fact that most ads for therapy lights show them being used incorrectly… 12-26-2013 8-16-16 AM

12-26-2013 8-15-22 AMThe picture on the left shows a blue light improperly set up (it is from the Mayo Clinic website) and the picture on the right shows a full spectrum light improperly set up (it is from the Harvard website)…

When you have set up the light check to make sure that you can see it with both eyes (close one eye and look towards the light, then close the other eye and do the same). You don’t need to look at it when it is on, but it should be in your peripheral vision.

Most people do other things while they are getting light exposure. For example, right now I am writing this blog post while sitting under a therapy light. Other people watch TV or read.

That is it.

Therapy light should help you to sleep better (more deeply) and feel more alert during the day within two or three days. And if you have a tendency to seasonal depression, it should help your mood almost as quickly.

Fall Mania

mania

I had been gearing up to write my usual set of posts about seasonal affective disorder, and then this afternoon I met with a young woman who has had a clear and consistent pattern of getting hypomanic in the fall.

We talk a lot about winter and fall depression. And, for many people, as the days get shorter and darker they find they are less energetic, want to sleep longer, perhaps even eat more. But there are also people who experience energized states (hypomania or mania) in the Fall.

Doctors Goodwin and Jamison, in their classic book, Manic-Depressive Ilness, note that, “Changes in light conditions are most rapid in spring and fall, and it may be that patients with recurrent affective disorders are more susceptible to rapid changes in the photoperiod.”

In other words, although the sun is brightest in the summer and dimmest in the winter, for people with bipolar what may trigger episodes is more the change in the amount of daylight, and the changes happen fastest in the spring and fall. This fits with an evolving model of bipolar that suggests that a major part of what leads to mood instability is unstable circadian (daily) rhythms

Most of the evidence for people with bipolar having a greater seasonality than the general population comes from clinical studies (studies of patients in a clinic) but there was one recent community study. In this study, Shin, et al. observed that:

Individuals with bipolar disorder experience greater seasonality than those with depression or healthy controls. Even the non-seasonal bipolar group had as much seasonal fluctuation as the seasonal depression group, which has important implications for the management of bipolar illness.”

While it is true that mania occurs more often in the spring, there is evidence that some people experience the reverse pattern. A research group at Harvard identified two seasonal patterns in bipolar. Type A consisted of  fall-winter depression with or without spring-summer mania or hypomania. Type B involved a spring-summer depression with or without fall-winter mania or hypomania.

Take home lesson – if you are bipolar, in the spring and fall it is especially important to focus on maintaining daily routines.

Get Ready for Fall

fallAs August winds itself up, it is time to start thinking about the fall and then winter coming up.

A little bit like the squirrels, who are already putting away food for the winter, it may make sense to make sure that you have what you need to have a happy and energetic fall and winter.

The first thing is to think about getting a therapy light. If you have any questions about there being a seasonal tendency to your periods of depression (if you think you may tend to get more depressed in the fall and winter), then now is the time to buy yourself one or two bright, therapy lights.

A therapy light is not like an ordinary light. It puts out a very bright light that is more similar in brightness to outdoor light than any indoor light that you find,  even in a very brightly lit room.

You have to sit pretty close to the light, so think about how you will set it up. Also, many of my patients find that 8-21-2013 5-52-35 PMit’s helpful to have one at home and one at work. The Blue Max Lighting Company in Canada makes several full spectrum therapy lights that are also excellent for reading and don’t look like anything other than a standard commercial light.

In addition to thinking about light, you may also want to give some thought now to the topic of how to stay physically active during the winter. During the summer you’ve probably been able to get out and enjoy the longer days, the better weather, in the fall and winter it becomes harder to stay physically active, but a continued high level of physical activity is essential to a good mood and good energy level.

So think about setting up a gym membership, buying an elliptical trainer (or some other home device) and be 8-21-2013 5-57-07 PMrealistic about how much time it will take to get to the gym and to do your workout and then to drive wherever you need to go. For many of us, having something at home, if we can use it regularly, is a better choice.

The Diamondback 1260Ef Elliptical Fitness Machine comes with a very high rating by an independent consumer magazine. And costs about 2200$. Which seems like a lot – but your health is perhaps worth the investment.

Finally, now is a good time to begin thinking about the upcoming challenges of the holiday season in terms of maintaining a healthy diet. Sketch out some ideas about what you can do to minimize the problems ahead. On average, Americans gain about four or five pounds during the holiday season and then lose about four of those pounds in the spring and summer. If you can cut back your weight gain, it will have a long-term effect in terms of boosting your energy and improving your mood.

Mary Poppins: Overcoming the Winter Months

winterWhat I most want to have available to me in the long winter months, to help me with my patients with bipolar and depression, is access to someone a lot like Mary Poppins.

You may remember that Mary, played by Julie Andrews, was the incredibly cheerful nanny who transformed the unhappy and dysfunctional lives of the family she joined.

What I particularly wanted Mary to help me with was getting people up and out of bed in the morning.  This is an absolutely essential thing to prevent mild to moderate depression from becoming severe depression.

The image that sticks in my mind is of her cheerfully drawing open the curtains in the morning and with her charm and good humor, getting a grumpy, tired, and depressed person out of bed and started with the day.

This thought came to me again as I was sitting with a woman who, when she is not depressed is in many ways a lot like Mary Poppins:  very cheerful, energetic, smart and charming. We were talking about how terribly hard it is for her, in the last few weeks, to get out of bed.

Maybe some day, I will actually go out and find people to do this unusual job. (The closest that I can find to someone to fulfill this role in the real world is a cheerful nanny – for those who have children – or a personal trainer – for those who don’t).

A cheerful nanny can be a life saver in a family struggling with the challenges of a new born and (perhaps) the very common post-partum depression. And a cheerful and energetic trainer, who may even stop by to go for a run or do calisthenics, can play a key role in helping a single person with depression begin to pull out of that state.

If either of these kinds of people might make sense to hire for you or your family think about it seriously. Maybe Mary will apply for the job!

[PS, if you are inspired to watch Mary Poppins again, be sure to notice the character of Uncle Albert, the sequence involving his tea party with Mary and the kids is a fun riff on the theme of bipolar moods].

Happy Winter Solstice

winterFor those of us in the northern hemisphere this is a day well worth celebrating. Today marks the shortest day of the year. Or, to put it another way, from here until summer every day will be a little bit longer, there will be a little bit more light, and eventually the days will get warmer and we will have spring.

Hopefully many of you purchased a therapy light this winter. The truth is, however, that no matter how “full spectrum,” artificial light doesn’t seem to be quite as good as natural light at lifting us out of a sense of lethargy or even depression.

Join me in celebrating the Winter Solstice which is perhaps the most universal (across almost all northern hemisphere cultures) celebration in the world.

  • Influenced by the Ancient Greek Lenaia festival, Brumalia was an ancient Roman solstice festival honoring Bacchus, generally held for a month and ending December 25.
  • The Winter Solstice Festival or The Extreme of Winter (Chinese and Japanese: 冬至; Korean: 동지; Vietnamese: Đông chí).
  • Christmas is observed on December 25, which was the Roman winter solstice upon establishment of the Julian Calendar.
  • Derived from a pre-Zoroastrian festival, Shab-e Chelleh is celebrated on the eve of the first day of winter in the Persian calendar, which always falls on the solstice. Yalda is the most important non-new-year Iranian festival in modern-day Iran and it has been long celebrated in Iran by all ethnic/religious groups.

Time Change: Fall Back

time changeThe time change in the United States is the classic “time of challenge and time of opportunity.”

First, the challenge – If you wanted to do something to make America more depressed you would be hard pressed to come up with a better intervention. Shift everyone’s schedule so that they wake up an hour later (according to the solar clock) during a time when the shorter days have already reduced exposure to morning light and tended to shift those who are vulnerable into a “hibernation” mode that looks a lot like depression.

The opportunity – So many of the people we have been working with have been complaining that they just can’t get up early enough… even though they know it would improve their mood… give them a chance to practice the “Morning Routine” and get some bright light exposure. Well, if you simply wake up at the same time (according to the solar clock) by getting up on Sunday and hour earlier than you would ordinarily do (according to the mechanical clock) you will have shifted your wake up time with minimal effort.

So, let’s take an example. Justin has been struggling to get up at 7 am for a month. He knows that if he got up at 7 am this would give him plenty of time to get his bright light exposure (45 minutes a day of therapy light) and to plan for his day in a thoughtful way, which would make him feel better all day. But honestly he has rarely been able to get out of bed before 7:45 am since the days started to get shorter.

On Sunday Justin can get out of bed at what would have been 7:45 am (OK we get that the Sunday piece of it is hard… but it might be a small price to pay for a successful transition in schedule that could make the rest of your winter more pleasant) but now is 6:45 am. And from now on (without actually making a change that his body clock should notice) he is up early enough to do the things he needs to to have a good day.

Or an alternative example, next week I will almost without a doubt have a clinic filled with people who are inexplicably more depressed, they took “advantage” of the extra hour to sleep in on Sunday, but actually by switching their wake up times later (by the sun) in the day they have done something that is one of the most reliable interventions to increase depression – phase delayed their sleep cycle.

Mom is Tired: Transactional Analysis

transactional analysisThe Winter Blues continue to be on the minds of people I talk to. One thing that sometimes happens when we get the blues is that we feel a bit abandoned, and one type of abandonment that is particularly significant emotionally is the abandonment by one’s mother. We have have had a number of conversations with themes related to Mom being too tired to take care of us…. Although Mom is often no longer around physically in our lives.

I have a certain fondness for the simplicity of Transactional Analysis. TA replaced Freud’s concepts of the “Superego”, “Ego” and “Id” with the notion of an internal “Parent”, “Adult” and “Child.”

In the language of TA, depression often is “about” our internal “Parent” becoming too tired to do the work of providing stability and safety for us. Which naturally leads to fear (and perhaps a dangerous “look what I can get away with”) coming from our internal “Child.”

One of our clients noticed that he was having more violent dreams, which were a bit scary. (He is not in any way a violent person, far from it). I interpreted this as a reflection of the fear that, with the internal parent less present, “maybe anything could happen.” An unrealistic fear, but an interesting way of expressing this psychological process.

OK, fine, but what to do about this.

One of our wiser clients suggested that perhaps that internal “Parent” needs a dose of the kind of “man up” advice that you can get from a good AA meeting.

Mom, you don’t get to disappear into the bedroom and leave the kids to run wild… you have to keep at it, providing stability and security even though you feel exhausted… Although it is OK to go to bed a bit earlier, and put off some projects that are not urgent or important until the boost of energy that accompanies spring arrives.

There is great value in the sense of commitment to the future that comes with having children. Equally, it is important to commit to one’s own future when feeling a bit depressed. Make sure that you are taking care of yourself. That you are following your healthy routines. And getting help if you really are too exhausted.

Bay Area Blues

bay area bluesIf you live in the bay area you probably noticed that this past week you felt a little less energetic. It was the first cold and rainy week of the season, and the days have been getting noticeably shorter (maybe you used to wake up after dawn and now it is dark).

We are naturally seasonal animals trying to live in a post-modern world that refuses to recognize our animal natures.

Almost everyone we saw this week reported feeling a bit slowed down, many said that they slept in a bit more or took naps they don’t ordinarily take. But they all had good reasons for doing this. And those reasons didn’t have to do with the change in season.

We have commented before that the brain is a remarkable explanation generating organ. But sometimes it is not as good at recognizing which explanations are probable and which are not.

In our leather chair, we could notice that we felt a bit slowed down ourselves, and really how likely was it that person after person that we saw had had particularly exhausting events take place in their lives?

Of course this seasonal shift isn’t exactly the same as depression. It is more like hibernation. Feeling more like sleeping during the day, eating more to prepare for the winter, less energy to think of new projects.

But if you tend to think of depression as an explanation for changes in energy you could easily see this as depression. Or if you have a life that really doesn’t tolerate a reduction in hyperactive multi-tasking, you could find yourself suddenly unable to “keep up.”

We suggest –

  1. Accept the inevitable. You will have to adjust your expectations and your pace a bit for the next few months.
  2. Focus on the morning routine. If you can’t hibernate for the winter the key to maintaining your energy is bright light, mindfulness, social contact and perhaps aerobic activity in the morning.

Have a good Fall.