Feeling SAD?

Seasonal Affective Disorder can present a unique set of challenges in people with MS. But there are ways to treat it.

by Brandie Jefferson

Joyce Glass was sluggish and had insomnia. She was moody. But she didn’t know anything was wrong.

“I thought everyone felt this way in the winter,” she says.

Her primary care doctor, however, picked up on the trend. “He said, ‘We have a problem here,’” Glass recalls.

The problem was diagnosed as Seasonal Affective Disorder, also known, appropriately, as SAD.

Glass, 60, lives in Ohio. She was diagnosed with multiple sclerosis when she was 49 but hadn’t suspected SAD when her doctor brought it up. He told her that her vitamin D levels were low, and he suspected her melatonin levels were off.

“He said, ‘You need more daylight. You need to spend time outside,’ ” she says.

She took his advice. “I didn’t realize how much of a difference it would make.”

What is SAD?

SAD is not just the winter doldrums. It’s a subcategory of clinical depression that usually affects people in the fall and winter, according to the American Psychiatric Association (APA), although it can occur any time of year. Current research suggests about 5% of adults in the United States experience SAD. It’s more common in women than men and in people living farther away from the equator.

Symptoms are varied, as with any kind of depression. According to the APA, however, people with SAD often report:

• Feeling sad or depressed
• Losing interest in things they once enjoyed
• Sleeping more but feeling more fatigued during the day
• Changes in appetite, including an increased craving for carbohydrates
• Difficulty concentrating

Glass likens her experience with SAD to a plant she keeps in her home. Through fall, the beautiful, shiny green leaves stand erect. “By the end of winter, the shine is gone. The leaves are kind of droopy and covered in brown spots,” Glass says. “In winter, I feel droopy, I have no energy. When I look at this plant, I feel on the inside the way it looks on the outside.”

What causes SAD?

There are several potential mechanisms by which the reduced light of fall and winter trigger SAD in some people. According to the Cleveland Clinic, most of those reasons relate to the reduced sun exposure. Any change in light exposure might throw people’s internal clocks out of balance. Those clocks do more than regulate sleep/wake cycles; they also help regulate mood.

Vitamin D also plays a role when it comes to regulating internal clocks. Our bodies need sunlight to synthesize vitamin D. And the hormone melatonin, which people produce at higher levels at night, is affected by exposure to sunlight. Overproduction of melatonin may contribute to feelings of sluggishness and feelings of depression in people with SAD.

“Ultimately, the biochemical nature of SAD doesn’t matter as much as how we manage it,” says Amy Sullivan, PsyD, a staff clinical health psychologist and the director of Behavioral Medicine at the Mellen Center for MS Treatment and Research at the Cleveland Clinic.

The Mellen Center offers people newly diagnosed with MS the opportunity to see both a neurologist and a mental health clinician at their first appointment. “Most patients take advantage of that in some shape or form,” Sullivan says. “It helps to normalize the need for mental healthcare.”

Whereas SAD is typically characterized by symptoms that are present for two to four months out of the year, Sullivan sees it a bit more in Cleveland, which has more than its fair share of “gloomy” days, according to Cleveland.com. “SAD is something we see about six months out of the year.”

In general, depression and anxiety disorders are three to four times more common in people with MS than in those who don’t have MS, Sullivan says. And having MS with SAD can lead to a unique set of challenges.

How to combat SAD

Getting more sunlight in the winter is the first and most obvious way to combat SAD, but getting outside in the winter can be challenging for some. “Take mobility or balance issues and couple that with a lot of snow and ice, and it can be really hard to get out and about,” Sullivan says.

Not only do winter conditions in many parts of the country make it difficult to get outside to soak up the sun. They also make it harder to get that all-important treatment for so many conditions: exercise.

Gina Villani-Raymond thought she’d figured out a way to get her exercise in the winter. The 48-year-old Indiana resident was diagnosed with MS in 1998. She had recently moved from Texas when, in 2020, COVID hit, presenting a double barrier to getting outside.

Her SAD caused insomnia and a feeling of general malaise in the winter, and she had difficulty concentrating.

“I said to myself, ‘I’m going to buy a stationary bike, go into the basement where it’s nice and cool, and I’m going to work out,’ ” she says. And that’s what she did. But for some reason, it wasn’t helping.

“It was great for exercise, but I thought, ‘why am I not feeling any better?’ ” she says. Exercise hadn’t done anything to help her mood, which she notices begins to plummet around the Daylight Saving Time change in November.

She soon realized that while the bike was great for exercise, “I was doing it in the basement, in a dark room, in winter, with no sun at all.” She was able to compensate with a light therapy box, which is a light that emits around 10,000 lux of light — about 20 times brighter than a typical indoor light.

“I bought one of those lamps, and it truly helps,” Villani-Raymond says. “I put it above my head, turn on Spotify and I exercise. And now I can sleep at night.”

Perhaps one of the trickiest lines to navigate when it comes to dealing with MS and SAD is heat sensitivity, a common symptom in MS, with people experiencing everything from extreme fatigue to pain to blurry vision. Essentially, any symptom that someone with MS has can be made worse by an increase in body temperature, which is not ideal when you’re trying to soak up all the sunlight you can.

For Glass, her first solution was to set up shop in the sun. “I set my puzzle table in front of my window,” she says, “and I put a bird feeder in the window.” She’s also intentional about being near a window when she sits down with a good book.

Glass is also planning to purchase a light box, but she noticed another change when her daughter, who lives with her, bought a pool. Even in the summer, Glass was feeling the effects of a lack of sunlight because she stayed inside to avoid the heat. But she can now sit outside and soak up some rays.

“I have a little floating lounge chair. I sit on it in the pool, and I let the sun just beat down on me,” she says. “And when I get too hot, I just roll over into the pool.”

Since spending more time outside, Glass says her vitamin D levels have gone up and her fatigue has gone down to the point where she no longer uses medication to stay awake and alert.

Like Glass’ primary care physician, Sullivan says she and her team are often able to spot SAD because of their long-term relationships with people who come to the clinic.

“We have the ability to see patients over the course of a lifetime. We notice trends, we have all of that information in our patient notes,” Sullivan says.

For people who don’t have close, long-term relationships with a healthcare provider, it’s important that if they notice any patterns resembling SAD, they bring it up with their doctor. “We can help patients figure out what works so that they don’t have to give up everything they love,” Sullivan says. “We want people to have joy. MS steals so much. We don’t want it to steal your joy as well.”

Brandie Jefferson is a writer in St. Louis, Missouri. She was diagnosed with MS in 2005