AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.
Featured topic and speakers
What does depression look like? What types of depression are there? What causes SAD? What are SSRIs? What are the signs that someone is depressed? What is seasonal affective disorder?
Our guest is Andrea DeSimone, DO, chair of the psychiatry department at Bayhealth Medical Center, discusses clinical depression, major depressive disorder, MDD and seasonal depression symptoms. Dr. DeSimone shares the latest in mental health research and treatment for seasonal affective disorder (SAD depression). AMA Chief Experience Officer Todd Unger hosts.
- Watch AMA Update for health care news for physicians, residents and medical students.
- Not a physician? Join the Patients Action Network.
- For more on signs and symptoms of seasonal affective disorder.
- Learn more about the AMA Health System Program.
- The AMA is your powerful ally, focused on addressing the issues important to you, so you can focus on what matters most—patients. We will meet this challenge together. Join us.
- Learn more about our AMA advocacy priorities, including:
- Reforming Medicare payment
- Fighting scope creep
- Fixing prior authorization
- Reducing physician burnout
- Making technology work for physicians
Speaker
- Andrea DeSimone, DO, chair of psychiatry, Bayhealth Medical Center
Transcript
Dr. DeSimone: Major depressive disorder, or MDD, is a serious health condition that causes persistently low mood, a loss of interest in activities you once enjoyed and an inability to feel pleasure or joy.
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about depression and seasonal affective disorder. We'll cover what distinguishes these two conditions and share advice for physicians on diagnosing and treating them. Our guest today is Dr. Andrea DeSimone, chair of the psychiatry department at Bayhealth Medical Center in Dover, Delaware. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. DeSimone, welcome.
Dr. DeSimone: Thank you so much for having me.
Unger: Well, before we dive into the specifics of each of these conditions, I think it would be best if we could just start by some general clinical definitions of depression and seasonal affective disorder.
Dr. DeSimone: Sure. Major depressive disorder, or MDD, is a serious health condition that causes persistently low mood, a loss of interest in activities you once enjoyed and an inability to feel pleasure or joy. To be diagnosed with major depressive disorder, a person must experience at least five symptoms of the condition, with at least one of them being a loss of joy.
While major depressive disorder is the most well-known form of depression, it's just one of several types. So there's also major depressive disorder with seasonal pattern, which is often called, in popular media, seasonal depression or seasonal affective disorder. Seasonal affective disorder occurs during certain times of the year, typically in the fall or winter months when there's less sunlight. And occasionally, people can have worsening of mood symptoms in the summer months, but that's much less common.
Unger: Dr. DeSimone, are the symptoms of MDD and seasonal affective disorder similar, or are there some key differences to be aware of?
Dr. DeSimone: So to meet the criteria for seasonal affective disorder, you must first meet the criteria for MDD, which, again, is having five of nine symptoms plus anhedonia, which is that loss of pleasure for at least two weeks.
These symptoms can be remembered by how medical students create the mnemonic SIGECAPS, and that stands for a change in Sleep patterns, a loss of Interest in things that you used to enjoy, feelings of Guilt or worthlessness, a loss of Energy, a loss of Concentration ability, changes in Appetite, changes in activity level, which is called either Psychomotor agitation, which results in a kind of restlessness, or Psychomotor retardation, which can look like you're stuck in the mud, thoughts of Suicide. And lastly, again, the patient must be able to have an inability to feel joy or pleasure.
Seasonal affective disorder is depression that occurs during certain times of the year and then resolves. This cycle must occur for two years to meet criteria for the specific type of major depressive disorder.
Unger: Dr. DeSimone, these days, we've heard from a lot of physicians in a wide range of specialties who are encountering patients with behavioral health issues, especially those in primary care. Do you have any advice to help them identify cases of MDD and seasonal affective disorder in their patients?
Dr. DeSimone: Sure. Depression can be invisible, so the first thing to do is to ask about it. In 2023, the United States Preventive Services Task Force recommended that all adults aged 18 years of age and older be screened for MDD at least once in their life. This can be done using a variety of freely available screening instruments, so this can include the Patient Health Questionnaire, which is the PHQ9, or the Geriatric Depression Scale. And there's no recommendation on how often to screen patients for depression.
Now this recommendation wasn't specifically made for primary care doctors, so meaning even subspecialty offices can screen patients. These patients may be going to see their specialist, but not a primary care doctor. So it's important to keep in mind that while a subspecialist may not be an expert in treating depression, but that doesn't mean that they can't be supportive to a patient who's in need. Many times, patients with MDD feel very alone, and that connection with someone who values them enough to take the time to ask about their mental health can be, quite literally, life-saving.
Unger: Well, based on your experience treating these conditions, what are some of the best practices that you would share with your fellow physicians?
Dr. DeSimone: So firstly, medications are not necessarily the answer to all cases of MDD. I know it can be super challenging to get in to see a psychotherapist, but psychotherapy can work wonders for patients with MDD. And medications should not be used in place of psychotherapy.
The medications that we use to treat depression are not benign. They have potentially significant side effects. So SSRIs, or selective serotonin reuptake inhibitors, which is the most common medication used to treat depression, they're generally well-tolerated, but they can cause significant sexual side effects in the majority of patients who take them, and they can cause clinically significant weight gain in adults. In older adults, they can cause hyponatremia, which is low sodium. So this is why I try to reserve medications for moderate to severe depression, and only after discussing these potential risks with my patients.
Secondly, if you are going to prescribe medications, you can likely titrate the medications faster than you think. I've seen many patients who have been sitting at their starting dose of an antidepressant for months, and this does no good for patients. It's demoralizing, and it's just not treating their illness correctly. So for context, in the inpatient psychiatric setting, so a very strictly controlled setting, I can increase the medication about every three days. In the outpatient world, I can make a dose adjustment about every week. You can check commonly-available databases for appropriate titration schedules, but most recommend weekly increases.
Unger: For that titration, what's your signal that you've reached the right point?
Dr. DeSimone: That is part of the art of psychiatry is to know when a patient's at an appropriate dose for them. When we start an antidepressant, we expect the patient to take about two weeks to respond in some way to an antidepressant. So at the beginning of a titration of an antidepressant, I'm not expecting them to have a resolution of their depression within two weeks. I'm expecting them to have some kind of effect during those first couple of weeks.
I'm also monitoring for side effects. There are some patients who will have a good response with a starting dose of a medication, but there are some patients who need a titration to the maximum dose. And the trick is that you don't know which patient is sitting in front of when you see them. So when someone tells me that they haven't had good effect with a starting dose of medication, to me, I say that's not a sign of the medication not working or the depression being too severe. We just have to see if you are able to tolerate a higher dose of the medication and if that will be helpful for you.
Unger: Well, the research on MDD and seasonal affective disorder is constantly evolving. Are there any new studies or emerging trends that physicians should be aware of?
Dr. DeSimone: Sure. Precision medicine is making its way into the mental health world. Precision medicine is an approach to health care that tailors disease prevention and treatment strategies to individual patients based on their unique genetic, environmental and lifestyle factors. There's some recent research from Stanford that shows that what we describe as MDD may actually be composed of several different biotypes of depression, which is characterized by different and particular brain activity, and each of these types may respond differently to certain treatments.
So for example, patients with one subtype that had overactivity in the cognitive regions of the brain had the best response to venlafaxine, which is an SNRI, a different type of antidepressant versus any other subtype. Those with another subtype, whose brains had higher activity in regions associated with problem-solving, had better effect with psychotherapy alone. So hopefully, in the future, we'll gain more clarity on predicting what particular interventions might work well for certain patients.
Unger: That is excellent news and the promise of precision medicine at work already. Dr. DeSimone, one of the most common questions that patients have about seasonal affective disorder is how to prevent it from happening in the first place. Is there a way that physicians can talk with their patients about that and give them advice?
Dr. DeSimone: Sure. While there is no sure way to prevent depression, there are absolutely some steps that patients can take to maintain a healthy lifestyle, which has been shown to impact mental health in a positive way. So first, a balanced diet rich in fruits, vegetables, whole grains, unprocessed foods can help reduce the risk of depression and may even support recovery for those already struggling with it.
But there's no strong evidence that any particular diet, such as a ketogenic diet or a gluten-free diet, vegan diet, Mediterranean diet is more effective in treating MDD than any others. But we do know that maintaining a healthy weight is associated with a lower risk of developing depression.
In terms of exercise, any physical activity is beneficial, but research suggests that activities like walking, jogging, yoga and strength training are especially effective for this. With seasonal affective disorder specifically, there are devices called light boxes, or some people will call them happy lights, that can help treat MDD. Unfortunately, the data is not there to say that they can prevent seasonal affective disorder, though.
So these are devices that mimic sunlight and are generally used for about 30 to 60 minutes daily, most people using them in the morning. They're commercially available. They can be purchased in a wide variety of places, so I would advise that patients look for devices that generate what's called 10,000 lux. It's a measurement of the light that's being emitted by these devices, along with minimal UV light, and that's to protect your eyes and your skin.
Unger: That's great advice. Dr. DeSimone, thank you so much for joining us today and sharing your expertise on these topics. For folks out in the audience, if you're a physician, you found this discussion valuable, you can support more programming like it by becoming an AMA member at ama-assn.org/join. That wraps up today's episode. We'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
Subscribe to AMA Update
Get videos with expert opinions from the AMA on the most important health care topics affecting physicians, residents, medical students and patients—delivered to your inbox.
