Seasonal Affective Disorder (SAD)

Seasonal affective disorder (SAD) is a type of depression triggered by the changing of the seasons. In most cases, it occurs along with the shortening of daylight hours in the fall and continues into the winter months. SAD typically resolves with the longer days of spring and stays in remission through the summer months. Other names for SAD include "winter blues" and seasonal depression.
   
Who gets SAD?  In the U.S., approximately 5% of the population meets the diagnostic criteria for this disorder, although up to 20% of people develop some of the symptoms.  The risk of developing SAD increases with aging and affects women more commonly than men. Those living in the more northerly latitudes with longer, colder winters are also at greater risk.

What are the symptoms of SAD?  Symptoms of depression, such as sadness, feeling "empty", and loss of energy are most typical of SAD. Other SAD symptoms include:

• Feelings of hopelessness and/or helplessness
• Irritability, restlessness
• Loss of interest in activities that had previously been enjoyable
• Difficulty sleeping or oversleeping
• Overeating and weight gain 
• Trouble with concentration or memory
• Withdrawal from social situations
• In severe instances, SAD can be associated with thoughts of suicide. 

How Does SAD Develop? SAD is thought to be caused by a chemical imbalance in the brain prompted by shorter daylight hours and a lack of sunlight in the winter. Melatonin, which plays a role in sleep patterns, and serotonin, a brain chemical that affects mood, are two of the brain chemicals involved in its development. With shorter daylight hours, more melatonin and less serotonin is produced which affects the body's internal alarm clock as well as its mood.

How is SAD diagnosed?  With the overlap of symptoms of SAD and certain medical disorders, such as hypothyroidism or viral infections, a medical evaluation is recommended for those who develop features of SAD. There is no specific test for SAD but the doctor may want to perform a physical exam and blood tests to rule out possible medical disorders. When the following are present: 1) seasonal symptoms of depression for at least two consecutive years, 2) periods of depression followed by improvement when the season changed, and 3) no other life events or circumstances can be found to explain the mood changes, the diagnosis can be made on history alone.

Is there a treatment for SAD? The most common treatments for SAD are light therapy, anti-depressant medications, and psychotherapy.

• Light therapy, also called phototherapy, is an effective treatment for many people with SAD.  Phototherapy involves the use of a light box containing special fluorescent lights with a color spectrum similar to outdoor light.  Sitting in front of this artificial light source for approximately 30 minutes each day is usually adequate to modify chemicals in the brain that are responsible for the development of SAD. This is usually done in the early morning, to mimic sunrise. Studies have shown that between 50% and 80% of users improve markedly with this type of treatment. It is important, however, that treatment is continued throughout the difficult season.  Another type of light therapy involves a light placed in the bedroom that gradually increases in brightness to simulate a natural sunrise. Side effects of light therapy are uncommon with irritability, eyestrain, headaches, and nausea being reported most commonly.
   
• Antidepressant medications are also effective for treating SAD and can be used along with light therapy.  The most commonly used anti-depressants are in serotonin selective reuptake inhibitor family (SSRI) family, which includes fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
   
• Psychotherapy is another option for treating SAD, particularly if light therapy and/or medications have not helped.  Psychotherapy appears to help by addressing negative thoughts and behaviors that are contributing to the depression rather than changing brain chemistry. 

Are lifestyle or alternative treatments effective? For those with mild symptoms of SAD, or to compliment standard treatment, a number of lifestyle measures may be considered. Whenever possible, get outside during the day for a walk. At home, open blinds or add skylights to let in sunshine. Exercise regularly for stress and anxiety relief. Remain socially active even if it requires some effort. Supplements used in treating depression, such as St. John’s wort, melatonin, and fish oil (omega-3 fatty acids), may help with SAD symptoms also.

Fact or Fiction, Wintertime Edition

See if you know the answer to these winter-related health issues, some true, some not:
   
Can a flu shot cause you to get the flu? 
A flu shot cannot cause influenza because it is either made with viruses that have been "inactivated" or with no flu vaccine viruses at all (recombinant influenza vaccine).  In a survey performed by the U.S. Centers for Disease Control, however, about a third of people who responded thought that it could. There are a number of reasons for this common misconception.  Rarely, the flu shot causes uncomfortable side effects such as fever, fatigue and muscle aches that could be interpreted as being the flu. Usually, however, the side effects are very mild, primarily consisting of soreness at the site of the injection.  A second reason for the misconception is because of the lag between receiving the shot and receiving immunity.  Since it can take up to 2 weeks for the flu shot to provide protection, it is possible that one could be exposed to the flu virus prior to the development of immunity.  Also, other viral illnesses, such as the common cold, are mistaken for the flu.  Lastly, since the flu shot is not 100% effective, it is possible that someone could contract the flu despite receiving the vaccination. A flu shot gives you the best chance for avoiding the flu, but it can't guarantee that you won't get sick.

 Is drinking alcohol and effective treatment for hypothermia? 
Despite the popular image of St. Bernard dogs carrying casks of brandy for treating avalanche victims in the Alps, alcohol is not effective for treating hypothermia.  Alcohol may feel like it warms the body, but that's because it flushes the skin with warm blood. Once the blood is at the surface of the skin, heat is rapidly lost through convection. You feel warm to touch, but at the same time, you're losing heat from your skin, so your core body temperature actually decreases.
 
Does becoming chilled cause a "cold"? 
It is commonly thought that becoming chilled can lead to a cold.  A few years ago, British researchers designed a study to look into this possibility. They took 180 volunteers, half of whom were required to immerse their feet in ice water for 20 minutes and the other half with their feet in an empty bowl.  Over the next four or five days almost a third (29 percent) of the chilled volunteers developed cold symptoms -- compared to just 9 percent in the control group.  The explanation offered by the researchers was that when colds are circulating in the community many people are mildly infected but show no symptoms. Becoming chilled causes a pronounced constriction of the blood vessels in the nose and shuts off the warm blood that supplies the white cells that fight infection.  The reduced defenses in the nose allow the virus to get stronger and common cold symptoms develop.  Although the chilled subject believes they have 'caught a cold' what is believed to have happened is that a dormant infection has become activated.  Maybe your mother was right about bundling up in the wintertime!

Does hand washing help prevent catching colds?
You bet it does, as well as helping to prevent the flu, other common viral illnesses, and food poisoning.  Hand washing is one of the simplest, easiest, and most effective public health measures. Amazingly, it is also one of the most overlooked.  Examples of when hand washing be should be done include:

• After blowing your nose, coughing, or sneezing
   
• When caring for someone who is sick or injured,
   
• After using the bathroom
   
• After touching your ears, nose, or mouth
   
• After changing diapers

Health care experts recommend scrubbing your hands vigorously for at least 15 seconds with warm soap and water; about as long as it takes to recite the alphabet. This will wash away cold viruses and many other disease-causing germs. It also will help prevent accidentally passing those germs on to others.

'Cotton kills' and other cold weather clothing wisdom

With the exception of people living in the most southerly climes, being outdoors in the winter means our relatively poorly insulated bodies will be exposed to the cold. This is where wearing the right clothing can make the difference between being protected and comfortable or vulnerable and miserable. The following common sayings related to dressing for the cold may not be completely accurate, but each contains a valuable message.

"Cotton kills" 
While this saying is somewhat of an exaggeration, cotton clothing ranks at the bottom of the list of appropriate fabrics for cold weather active wear.  With outdoor activity, perspiration is absorbed into cotton layers that are touching or near the skin. As the air pockets in the fabric fill up with water, it ceases to provide insulation. A damp layer of clothing against the skin pulls heat away from the body and can rapidly lower body temperature. Furthermore, wet, cotton clothing takes much longer to dry than comparably weighted synthetic fabrics.  Garments labeled as corduroy, denim, flannel, or duck are mostly, or entirely, made from cotton. Clothing made from synthetic fabrics or wool is more appropriate, particularly during physical activity in the cold.

"If your feet get cold, put on a hat"
The notion that the body loses more heat from the head and neck has been somewhat dispelled. Studies have shown that the rate of heat loss is essentially the same for any exposed area of the body. Since the area of the head and neck makes up approximately 10 percent of body surface area, this area accounts for a similar percentage of heat dissipation. It is still a good idea to put on a hat and scarf when outdoors in cold weather. Most people find covering the head and neck to be more comfortable when in the cold and it provides a means to ventilate quickly by removing the hat if you overheat.
 
 "Dress in layers"
There are a number of advantages to dressing in layers rather than wearing a single heavy garment.  The basic idea is that warm air is "trapped" between the layers providing more warmth to the body.  Also, it is possible to choose layers that each contribute to a "system", with special layers designed to keep the skin dry, provide insulation, and to protect us from wind and rain.  Synthetic fabrics, such as Capilene, work best as base layers, worn against the skin. These fabrics keep the skin dry by "wicking" moisture away. A middle, insulating layer of wool, synthetic fleece, or Thinsulate works by trapping air to keep you warm. Goose down is also a great insulator, but it loses almost all of its insulating properties should it become wet. The outer shell layer should be both windproof and waterproof.  Ideally, this garment also "breathes" to allow moisture to escape from the body.  Gore-Tex and Entrant are trade names of fabrics with these characteristics. Using layers of clothing also allows you to control your temperature more effectively. Should you become overheated or begin to sweat during activity or exercise, you can remove or open up a layer to ventilate. As you cool down, zip up or add a layer.
 
 "Mittens are warmer than gloves" 
To a large degree, the warmth of mittens or gloves depends on the insulating properties and thickness of the materials used in their construction. When constructed similarly, however, mittens are warmer than gloves because the extra air inside create added insulation, and because fingers maintain their warmth better when they are touching.  "Dressing in layers" can apply to the hands also. For example, a thin glove liner beneath a mid-weight glove or mitten can be warmer than a single heavy glove.  Be sure that your gloves are not too tight – constricting circulation can lead to cold hands.  If exerting yourself in cold, wet conditions, consider carrying a spare pair of gloves or mittens in the inside pocket of your jacket. This gives you a warm, dry set of hand wear to put on should your fingers become cold.

An old Norwegian saying sums it up: "there is no such thing as bad weather, just bad clothing".  Wintertime can be a wonderful time to get outside, but not if your clothing is not up to the task.  A little preparation and the right combination of clothing can make all the difference in your winter outdoor enjoyment.

A new way of looking at cold symptoms

There's no denying that the typical symptoms of the common cold---sore throat, runny nose, cough, etc. ---are miserable.  But when you realize that cold symptoms are an indication that your body's defense system is working, it gives you a different perspective on your misery.
   
Up to 50% of colds are caused by a class of viruses known as rhinoviruses. Typically the virus enters its victim's body through the nose, either by contaminated fingers or droplets produced by coughing or sneezing.  Once inside the nasal passages, the virus reproduces rapidly with cold symptoms beginning as soon as 12 hours after exposure to the virus. Symptoms usually peak after 2 to 3 days, and in most cases, resolve after a week.

When the body is infected by a cold virus, the immune system is activated to fight the infection. Initial responses of the immune system are to send white blood cells to the site of the infection and to release chemicals known as inflammatory mediators, including "kinins".   These inflammatory mediators cause tissue swelling, increased blood flow to the nasal cavities, and the production of mucus---many of the features that we identify as "cold" symptoms.  Recently, an antiviral compound known as "viperin" has been identified that also plays an important role in fighting rhinovirus infections.  These and many more responses from the immune system are essential in helping us get over a cold.

Let's look at some of the symptoms produced with a cold and what they may imply about the infection or the body's response to the infection:

• Scratchy or sore throat:  This is frequently the first manifestation of a cold.  It is thought to be caused both by damage to the mucosa from the virus as well as by inflammatory mediators that come in contact with sensitive nerve endings.
   
• Mucous drainage:  Initially, the watery drainage is thought to come about from inflammatory mediators, such as bradykinin.  The thicker, discolored drainage is related to mucocilliary clearance, an important defense mechanism in which mucous is produced to help transport infecting organisms out of the body.
   
• Cough:  This is also thought to be a component of mucociliary clearance.  Movement of hair-like structures (cilia) lining the respiratory tract and coughing help to move virus-containing mucous out of the lungs.
   
• Stuffy nose:  Blockage of nasal passages is a common feature of most colds. One of the inflammatory mediators in particular (bradykinin) is known to bring about increased blood flow and leaking of blood vessels leading to this symptom.

Some medical writers have reasoned that the more severe the cold symptoms one is experiencing, the stronger the body's immune system response.  This is perhaps a poor consolation to feeling so uncomfortable, but just remember that along with these symptoms comes the knowledge that your body is doing its best to fight the infection.

Overused and Unnecessary Medical Treatment under Scrutiny

The American Board of Internal Medicine is leading a health education campaign to inform patients and physicians about the overutilization of medical resources.  This program, known as "Choosing Wisely", includes recommendations for medical professionals as well as for the public.  It was developed "to help providers and patients engage in conversations about the overuse of tests and procedures and support efforts to help patients make smart and effective care choices."

It has been estimated that up to 30 percent of medical care delivered in this country is unnecessary and in some cases may even cause harm rather than providing benefit.  Avoiding unnecessary tests and treatments is not only in the best interest of patients but it provides cost savings to individuals and to society.
  
The campaign currently includes input from around 70 U.S. medical specialty societies and has partnered with the non-profit consumer organization, Consumer Reports, to help disseminate understandable medical information to the public.   Participating medical groups provided a list of five tests, treatments or services that are commonly overused by that specialty, with the intent that the information will be shared with other members of that specialty group as well as with patients and local community groups.  The following are just a few of the items submitted to the campaign:  

1. Removing dental fillings that contain mercury is unnecessary (American College of Medical Toxicology and the American Academy of Clinical Toxicology).

So called "silver" fillings are actually made of a material called amalgam which is an alloy of several metals including silver, mercury, tin and copper. Due to concerns regarding mercury intoxication, many people are opting to replace amalgam fillings with a non-mercury containing alternative. Replacing silver fillings is felt to be unnecessary because the fillings contain very small amounts of mercury and studies have not shown any harm from this source of mercury.  Replacing silver fillings can also be expensive and can potentially weaken the tooth requiring additional dental work, such as the placement of a crown.   Amalgam fillings should be replaced only when they are worn, broken or when there is decay beneath the filling.

2. Imaging tests, such as x-rays, CT scan or MRI, are usually not required in cases of back pain (American Academy of Family Physicians). 

Most episodes of back pain resolve within a month whether the person undergoes an imaging test or not. Furthermore, receiving an imaging does nothing to speed healing.  X-rays and CT scans expose people to radiation needlessly.  Imaging tests are expensive, ranging from around $200 for back x-rays to $1,000-1500 for a CT or MRI scan. There are, however, some clear indications for when an imagining study should be obtained in someone with back pain including unexplained weight loss, fever, loss of bladder or bowel control, and a history of cancer.

3. Try non-surgical options before considering surgery with plantar fasciitis (American Orthopaedic Foot and Ankle Society).

Plantar fasciitis is a very common cause for pain in bottom of the heel. The classic symptom is pain upon taking the first few steps after getting out of bed in the morning. The cause is inflammation of a band of tissue called the plantar fascia that runs from the heel to the ball of the foot. Surgery for plantar fasciitis should be viewed as a treatment of "last resort".  Non-surgical measures including stretching exercises, use of arch support or custom foot beds, taking an anti-inflammatory medication (e.g. ibuprofen) or wearing a splint at night to stretch the plantar fascia should be tried before surgery is considered. Surgery for plantar fasciitis can be costly (up to $10,000) and can be associated with a number of complications including nerve damage, permanent "flat feet", and more pain than was experienced prior to surgery.

4. Colonoscopy more often that once every five or ten years is rarely needed  (American Gastroenterological Association)

While there are several methods of screening for colon cancer, colonoscopy is considered to be the most accurate test available. When colonoscopy is the chosen method of screening, it is generally recommended to be initially performed at age 50 and repeated at 10 year intervals. Colon cancer usually develops slowly, stemming from a pre-malignant polyp known as an adenoma. If no polyps are seen during colonoscopy, the procedure can safely be repeated in 10 years. When adenomas are seen and removed, a follow-up colonoscopy in 5 years is often recommended.  Unless someone is at high risk of developing colon cancer, undergoing the procedure more often than this is unnecessary.  Other reasons to restrict the frequency of undergoing colonoscopy include its expense, the risk for complications, and the inconvenience of the procedure.

5. Antibiotics are usually not needed in children with respiratory infections (American College of Pediatrics).

Antibiotics are used to treat bacterial infections. They are not effective against viruses, the organism responsible for most colds, sinus infections and respiratory tract infections. Unless someone's immune system is compromised, the body's immune system will take care of these infections. Anytime antibiotics are taken there is a risk of an allergic reaction or side effect. Also, overuse of antibiotics promotes the growth of "resistant" bacteria that do not respond to commonly prescribed antibiotics.  Situations in which the use of an antibiotic may be considered include: 1) a persistent or worsening infection, 2) a confirmed bacterial infection (whooping cough, strep throat, etc.), and 3) fever (temperature at least 102 degrees) lasting for several days.

The "Choosing Wisely" site is very user-friendly and offers a wealth of information regarding rationale for performing or not performing many medical procedures, tests, and treatments. Rather than making absolute recommendations, however, a primary goal of this campaign is to promote a dialogue between patients and health care providers regarding the judicious use of medical interventions.

5 Second Rule, the “research” continues

Have you ever heard anyone invoke the "5 second rule" after dropping a piece of food on the floor?  The idea behind this rule is that food that is picked up in fewer than 5 seconds after hitting the floor has not had time to attract germs, and is safe to eat. The rule goes on to imply that food remaining on the floor longer than 5 seconds is likely to have become contaminated and should not be eaten.
   
While this rule has been tested on the Discovery Channel's MythBusters in a quasi-scientific manner (and by the way, did not pass muster), it has also been evaluated in at least three, more rigorous, scientific studies.  The first report evaluating the "5 second rule" was published by a researcher at the University of Illinois in 2003.  This study involved dropping gummy bears and fudge-striped cookies onto floor tiles that were contaminated with E. coli bacteria (a preliminary survey performed by this researcher had indicated that people were more likely to pick up candy than, say, broccoli).  In every instance, the food items became contaminated in 5 seconds or less, dispelling the notion that it is safe to eat food that has been on the floor for any length of time.
 
Claiming that this study was not representative of what actually happens in the "real world", two student-researchers at Connecticut College designed a study to test the rule in an everyday environment.  They dropped food samples (apple slices and Skittles) onto the floors of the college dining hall and snack bar. The food samples were allowed to remain on the unaltered floor for various lengths of time from 5 seconds to 5 minutes. Interestingly, no bacteria were present on the foods that had remained on the floor for 5, 10 or 30 seconds, lending support to the "5 second rule."  The apple slices did pick up bacteria after one minute, however, and the Skittles became contaminated with bacteria after remaining on the floor for 5 minutes.

The most recent study on the subject, performed at the Aston University's School of Life and Health Sciences in England, found similar results as the "Skittles" study. While the initial contact of various foods with the floor was found to transfer a small amount of bacteria, the longer that food remained on the floor the greater the contamination. Moist foods left on the floor for longer than 30 seconds picked up 10 times more bacteria than when picked up prior to the 5 second "deadline".  Interestingly, carpeted floors were less likely to transfer bacteria to a dropped piece of food.

 My take on this rule: if food lands on a contaminated surface it can pick up disease-producing bacteria almost immediately. If it lands on a clean surface, it could conceivably remain safe to eat for hours.  The problem is that without biologic testing of the surface, it is impossible to know if the surface is clean or contaminated. It is probably true; however, that the shorter the period of time that food remains on the floor the less likely it is to attract bacteria.  The next time you see someone drop some food on the floor, rather than calling out "5 second rule" it is probably best to say, "When in doubt, toss it out".