Below is an interesting article on SAD and light boxes from this week's Washington Post:
A SAD Solution
Study: Talk Therapy Beats Light Box for Seasonal Depression
By Cecilia Capuzzi Simon
Special to The Washington Post
Tuesday, January 13, 2004; Page HE01
For those with seasonal affective disorder -- also known as SAD, a form of depression brought on by the dark days of winter -- light therapy (LT) is the standard treatment.
For at least an hour a day, patients sit in front of a box that emits white fluorescent or full-spectrum light. The treatment is believed to help compensate for a person's decreased exposure to the sun during winter's short days, yet 47 percent of patients overall and 57 percent of those with moderate or severe cases of SAD do not respond fully to it. Compliance is low and relapse is common.
Those sad facts drove researcher Kelly Rohan, an assistant professor of medical and clinical psychology with the Uniformed Services University of the Health Sciences in Bethesda, to study the effectiveness of cognitive behavioral therapy on SAD.
Cognitive behavioral therapy, or CBT, is a form of talk therapy in which patients are taught to identify and change the thoughts and behaviors that lead to their symptoms. One of the most thoroughly studied mental health therapies, it's been proven effective at reducing symptoms of anxiety, depression and other psychological problems.
Rohan's finding? CBT alone was more effective than LT alone, and 80 percent of patients responded completely when the therapies were combined. Those who received CBT also had dramatically lower rates of relapse.
Rohan says it makes sense to use CBT to treat SAD, which afflicts about 5 percent of adults in the Washington area, according to an estimate by the National Institutes of Health. Though SAD is brought on by the body's inability to adapt to seasonal changes, Rohan believes that the biological explanation alone is simplistic. A large cognitive component of the disorder is often overlooked, she says. A person's thoughts in response to those changes are also responsible for the symptoms, she says.
For individuals with a history of becoming depressed in the winter as days shorten and circadian rhythms are disrupted, the season -- and even its approach -- "takes on a certain meaning," she says. "Many patients expect their symptoms to begin" as the fall nears. "My phone starts ringing in August," she says. "Physiologically, there is no reason for symptoms to begin that early."
Many SAD patients, she explains, take cues from the environment -- changing leaves, dropping temperatures, less daylight -- and depressive symptoms and behavior become a learned response. "They go into hibernation mode in anticipation of the winter -- staying indoors, or in bed, and cutting off social interactions, activities and exercise," she says. All are symptoms of generalized depression.
Rohan's study does not disprove the usefulness of light therapy, but she hoped it would identify an alternative or at least complementary therapy for the disorder and address LT's shortcomings. For example, even those who do respond to LT suffer what Rohan calls "residual" symptoms: LT-induced improvement is not as complete as spontaneous remission in the summer months.
In addition, adhering to LT protocol is difficult. "It's hard enough to get a patient to take a pill as prescribed for depression," Rohan says. "Imagine trying to get them to sit in front of a light box up to two hours a day. Fifty-nine percent of patients discontinue use. It's a nice treatment. It's effective. But if people can't comply long-term, that's a problem."
Rohan's study compared three groups -- those treated only with LT, those treated with CBT and those treated with both.
All three groups improved, based on two depression-rating scales. But those who received CBT, either alone or with LT, were less depressed at the one-year follow-up. And in one of the depression-rating scales administered the winter following treatment, not one CBT participant -- with or without LT -- met the criteria for depression. By comparison, 62.5 percent of LT-only participants met the depression criteria the next year.
"Light therapy doesn't teach people anything they can do to cope with stress and depression," Rohan says to explain the low relapse rates for those who had the talking cure. "CBT teaches skills that can be used in other areas of life."
People in Rohan's cognitive therapy groups attended group sessions twice a week for six weeks. During those meetings, they learned about the biological origins of SAD and also about the learned behaviors and ingrained thought processes that Rohan believes contribute to their symptoms. They were taught how to alter behavioral patterns in the winter to "get them to act more like they do in the summer," Rohan says, developing interests and activities for the colder months and making efforts to maintain social contacts.
CBT participants also were required to identify negative thoughts and write them down. This helped them develop a greater awareness of what affects their moods, Rohan says, and provided opportunities to challenge their thinking. Lastly, participants were taught to recognize SAD's early warning signs to help prevent relapse.
"We got them to push themselves even when they didn't feel like it," Rohan says. "When they did, they got relief and were able to do more. That created a positive upswing so they could do even a little more the next time."
Clinical Trial
Rohan is assembling another group of SAD patients for additional research. Anyone interested in participating can receive information by calling 301-295-3241.
Cecilia Capuzzi Simon is a regular contributor to the Health section on psychology topics.
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