Well, its that time of year again. If you're feeing a little blue about winter approaching, read on.

1. What is seasonal affective disorder (SAD) and how is it different from winter blues or other types of depression?

• Seasonal affective disorder, also known as winter depression, is a lowering of mood that occurs in the winter months. As the nights draw in through autumn sufferers notice a lack of energy, low mood, and the desire to spend more time in bed – but the sleep is not refreshing. Carbohydrate cravings can become strong which, combined with tiredness, lead to reducing exercise and a spiral of low self-esteem and withdrawal.
• Seasonal affective disorder looks very similar to depression so some doctors do not consider it a separate diagnosis. It is more common in women and affects approximately 3% of the population. Winter blues is a milder form of the same condition.

2. Top tips for avoiding SAD?

• If you had SAD last winter or you might be prone to it, watch out for the signs as the days get shorter. If you are not sure, plot your daily mood on a chart.
• Try to keep exercising, just a little every day. Be careful not to push yourself too hard. Walk whenever you can during daylight hours as this gives both exercise and exposure to natural light. Even when it feels difficult, remind yourself that you are doing something positive for your body.
• Be mindful of carbohydrate cravings. Brown rice and sweet potato make good alternatives. Even if you succumb to cakes and chocolate, all is not lost. Keep up regular meals to maintain your nutritional intake and add a multi-vitamin. Try to limit the amount of alcohol and stay well hydrated with warm drinks like herbal teas.
• Keep your usual routine and social engagements as this helps maintain your sense of wellbeing. You may need to bring some wisdom to your social calendar to ensure you get good rests and don’t spread yourself too thinly.

3. What are the types of treatments available for this condition, and at what point would you advise people to seek treatment?

• Think holistically – tell your loved ones what to expect and how best to help you.
• Light boxes and dawn simulating alarm clocks that mimic natural light can also help.
• Some people find antidepressants beneficial, especially if they have depression at other times. For best results seek advice from your doctor sooner rather than later. Psychological therapy such as CBT (cognitive behavioural therapy) offers mood management strategies.

4. Is there a cure for this condition?

• Like depression, there is no cure, so the key is to get to know your individual pattern of symptoms and take control of how you manage them.
• Explore what works best for you and get the support you need from professionals, family and friends. Most importantly, remember to be kind to yourself – this condition is not your fault and you are doing your best. Remember that things will get better in the spring.

For more information see: Light therapy and the management of winter depression. John M. Eagles: Advances in Psychiatric Treatment May 2004, 10 (3) 233-240; DOI: 10.1192/apt.10.3.233
 

Here are some facts about depression, then a comment on some fascinating new research about inflammation and the brain. It gets a bit technical but is worth the read!

Causes of depression

We don’t know what causes depression. The predominant theory for the past few decades pertains to reduction of two neurotransmitters in the brain (Serotonin and Noradrenaline) Neurotransmitters are molecules that pass between nerve cells and between nerve cells and their supporting  glial cells, enabling them to communicate. The recent article by Setiawan et al in JAMA Psychiatry illustrates a growing interest in the role of inflammation as a potential cause.

Depression affects around 300 million people worldwide (WHO) and is projected to increase, with the greatest increase in the uk being in those over 75 (according to the Kings Fund think tank). Depression is a serious illness, robbing people of their enjoyment of life. It is accompanied by a high level of disability – in severe case people can become bed bound, unable to care for themselves or enter a type of stupor. At its most severe, depression can lead to suicide.

In many cases it is a recurring condition. Single episodes tend to last several months. It is also a costly condition from a national perspective as the cost services to treat depression for the whole of England in 2007 was approximately £1.7 billion. If you include the amount from lost employment the total comes to £7.5 billion. We are fortunate in this country, however fewer than half of those affected worldwide have access to adequate treatment and health care.

Symptoms of depression:

WHO: Depression is characterized by sadness, loss of interest or pleasure, tiredness, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration which can feel like a poor memory. There can be many  physical complaints with no apparent cause such as back pain or tummy pain.

However depression is often used as a catch-all term for a range of mental health conditions. In a way this is good, as it shows there is very little social stigma these days in having this diagnosis. But it is important to get the diagnosis right, so that people can get the right treatment. Many other conditions  such as anxiety, eating disorders, harmful alcohol use and some physical conditions such as heart attacks,  commonly co exist with depression.

Andreas Lubitz, the Germanwings co pilot who intentionally and tragically crashed a passenger plane on 24th March was described as having depression. Yet he did not seem to have any of the symptoms – his problems seemed more to do with anger, possibly rejection, inadequacy and fear. No doubt he was sad at times and may have had co-existant depressive episodes, but that was not his only problem. Describing someone like him as having depression can lead to stigma of genuine sufferers.  People with depression are mostly a risk to themselves and not to other people.

Inflammation and depression

Translocator Protein – TSPO -  is located exclusively in glial cells therefore it can be used as a marker for reactive gliosis (Reactive gliosis comprises the activation of microglia and astrocytes and is a hallmark response of the CNS to injury – Chen and Guilarte 2008) Before this was discovered, the only way to tell was from a tissue sample obtained through biopsy or post mortem. The location of the TSPO gene is in the q13.3 region of the long arm of human chromosome 22 (Riond et al., 1991).

Under normal physiological conditions TSPO levels in the CNS are very low and limited to glial cells (astrocytes and microglia). Microglia constantly survey their environment and have the ability to respond to brain injury within minutes by directing their ramifications to the site(s) of damage (Nimmerjahn et al., 2005). They proliferate and migrate to the sites of brain injury (Kreutzberg, 1996; Streit et al., 1988,1999 and 2000), characteristics that are not possessed by astrocytes (Chen and Guilarte 2008) which are more to do with supporting new growth of damaged neurones.

A dramatic increase in TSPO levels occurs  in response to brain injury or inflammation.  Despite many studies showing this increase, the mechanisms and physiological implications of how and why TSPO responds are still not known (Chen and Guilarte 2008)

It is measured through a minimally invasive technique -  a small amount of a weak radioactive chemical  (called a radio ligand) is injected which temporarily binds to the TSPO  in the brain.   A type of brain scan called a PET scan can detect these small amounts of radioactivity and show it as a picture on a screen. So this can theoretically be used to monitor disease progression and to assess the  effectiveness of treatments. Since the 1900s, research teams have been using this technique to work out which parts of the brain are inflamed in a number of conditions such as stroke, MS and alzheimers dementia.

Brain inflammation is associated with many neurological conditions (stroke, head injury and some dementias).  Setiawan et al’s paper is important because it is the first study that definitively links markers of brain inflammation with a mental (rather than physical) illness,  bringing the concepts of depressive illness closer to that of a physical illness.

Setiawan et al summary: They used PET scanning (isotope with affinity to TSPO) to identify the distribution volume (amount) of Trans locator Protein expression in brain areas of people with MDE compared with controls. TPSO is a protein that is expressed on the outer membrane of mitochondria in microglia. They chose to measure this because one reason for increased TSPO expression is neuro inflammatory process. They had 20 people with moderate to severe MDE and 20 age matched controls.

They found that TSPO expression is increased in people with MDE and this appears to be linked to severity of depressive symptoms as recorded by the HDRS.

They assume that this TSPO expression is the result of microglial activation (microglia are monitoring and support cells in the brain which can become activated to respond to infection) and thus an indication at the cellular level of an inflammatory or immune mediated process.  They make this assumption because of past studies that showed that  i) induction of inflammation in humans is associated with depressed mood (27 ,39) and ii) that direct induction of central inflammation in rodents is associated with anhedonia. However they acknowledge that TSPO expression can arise for other reasons such as i)  translocating cholesterol from the outer to the inner mitochondrial membranes for steroid hormone synthesis and ii) participating in the mitochondrial permeability transition pore hetero-oligomer, which influences predisposition toward apoptosis (programmed cell death). So there is no guarantee that the TSPO that they measured in their scans had anything to do with depression.

Also, this increased TSPO expression is not linked to increased expression of  inflammatory markers in the peripheral system (similar results have occurred in other studies). A Danish study also published in JAMA Psychiatry (2013) showed a link between psychological distress (beyond that of typical stress) and CRP serum levels.

This study is not saying that when you are depressed your brain becomes inflamed (like a hot and swollen sprained ankle). It is only saying that there is evidence that some of the cells involved in the inflammatory response are more active or more numerous in some areas of the brain in people with severe depression. They are also not saying whether this is cause or effect. Another study (Otte et al)  has shown correlation between  one allele (version) of the serotonin transporter and increased adrenaline and it has been suggested that there is a link between depression,  stress, and heart disease possibly related to inflammation. Again, more studies are required.   
It is early days with this fascinating and important research, so we don't know for sure how clinically useful this will turn out to be. One reasons is because these changes in TSPO occur long before there is any visible structural change to the brain tissue itself.

One paper has proposed that exercise is a  common mechanism that might be related to inflammation. (Exercise builds brain health: key roles of growth factor cascades and inflammation. Cotman et al, Trends in Neurosciences,  Volume 30, Issue 9, p464–472,2007) ,.

After all this,  it is tempting to think then that we should take anti inflammatory medications (like ibuprofen)  for depression however a meta analysis  (Effect of Anti-inflammatory Treatment on Depression, Depressive Symptoms, and Adverse Effects A Systematic Review and Meta-analysis of Randomized Clinical Trials Ole Köhler et al JAMA Psychiatry. 2014;71(12):1381-1391) did not find any conclusive results. So we should be careful about over interpreting Setiawan et al's results for now. And obviously all drugs come with side effects, including anti inflammatories.

Despite these fascinating advances, it is important to remember that depression is a serious illness and people do sadly take their lives as a result. People suffering with depression should be encouraged to seek help and support. Talking therapies such as  CBT and psychotherapy have also been shown to cause brain changes and it is important that people seek help if they are concerned.  

Having a second child is incredibly rewarding as well as challenging. It is important to consider how you will take care of yourself whilst still attending to your older child’s needs.  Essentials like sleep and nutrition are especially important - poor sleep has been linked with depression, so make sure you have sufficient support to enable you to rest. According to one mother, trying to find the time and energy to dedicate to each child can be exhausting -  put pride aside and accept every offer of help.  

Your older child will have a routine so aim to keep this going as much as possible, but don’t feel guilty when circumstances get in the way. Having a second baby is uncharted emotional territory and can feel different, even for both parents. One mum of two said “I've never failed at anything as much as I have at parenting  - at least that's what it feels like!”.  Try to acknowledge what is going well, and forgive yourself for mistakes. You are doing your best and children born into a loving environment are incredibly resilient. Finding other parents with whom you can speak openly can be validating.

Low mood or anxiety during and after pregnancy is quite common, for both parents. This can happen even if a previous pregnancy went smoothly and is more likely if your circumstances are stressful. It is difficult to ask for help, but most parents will come through this with the right support (for example: http://www.mind.org.uk/information-support/types-of-mental-health-problems/postnatal-depression/#.VMat2NKUeSp). Occasionally, women may feel anxious about a second birth, especially after a previous C-section. This is a normal reaction and midwives and birth Doulas can offer support.

If you have a partner, discuss your expectations about a second child. It will be harder to find time to talk so set review points and stick to these. Your children will have different temperaments, right from the start, so discuss how this is impacting on you and think about the best approaches you can offer to each child.  You can help your older child adapt by allowing them to express themselves through talk or play and encouraging them to build a relationship with the new baby even before the birth. Aim to find fairness with all your children and accept that this can also be a challenge.

Published in Smallish Magazine - March 2015 
http://www.babyandmemagazine.co.uk/

It is not a coincidence that 8 of National Geographic’s 10 happiest cities are found on the shores of lakes or seas.  Another, Kuala Lumpur, like many cities is at a river confluence.

It is impossible to separate our emotional wellbeing from where we live. Indigenous peoples know this, as reflected in some models of health care: http://tearawawhanauora.org.nz/2013/11/maori-models-of-health-wellbeing/

For Maori, connection to the land (Whenua) is essential for wellbeing. It gives a sense of identity and simultaneously places them in the present, in their ancestral past and in their childrens’ futures. Without it, cultural disenfranchisement occurs leading to depression, alcoholism and poor social outcomes, both as individuals and as a people.

Western cultures tend to forget about this – I have never heard a western doctor ask a patient about this and I suspect we don’t have the language to express it.  Our hyper-developed urban sprawls make it hard to observe and understand the rhythms of nature, even at the fundamental level of contemplating a beautiful view.  Possibly this is cultural disenfranchisement on a continental scale?

Living by the sea enables us to more easily respect these connections and incorporate nature into our daily lives. The human spirit yearns for this, even as we build our way further inland.

Participation in society is another key to mental well being. Monterrey, although not by the sea, is on the list because its residents have got the work life balance right. Have you?

http://travel.nationalgeographic.com/travel/photos-top-10-happiest-cities/

Vitamins are organic (carbon containing) compounds that are essential for life and which we must get from food as our bodies cannot make them.

Because the B vitamins are water soluble they cannot be stored in the body, so we need to replenish them often. This is why I have listed  below, the foods where each vitamin can be found.

I have described  here the main B vitamins involved in maintaining mental wellbeing. Although the role of B vitamins and mental health is not completely clear, there are some interesting links worth bearing in mind particularly regarding depression.

The main articles I have referred to in writing this post are:
http://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-B.aspx
Ramsey and Muskin, Current Psychiatry Vol. 12, No. 1 http://www.currentpsychiatry.com/fileadmin/cp_archive/pdf/1201/1201CP_Ramsey.pdf

 
VITAMIN B1 (also called: Thiamin / Thiamine)
This is essential in glucose metabolism, it also keeps nerves and muscle tissue healthy
It is rare to be deficient in B1, although it is a well known consequence of alcohol misuse. B1 deficiency may be also more common in people with diabetes. Its deficiency can contribute to anxiety and depression symptoms arising from blood glucose changes.

Where is it found?
Many types of food including:
Vegetables, peas, fresh and dried fruit, eggs, wholegrain breads, liver, some fortified breakfast cereals.

You need to eat it every day as you cannot store it!

 Vitamin B2 (also called: Riboflavin)
Vitamins B2, 6, 9 and 12 are key cofactors in the methylation cycle. This is an extremely important, but complex, chain of reactions that happens all the time in our bodies. The methylation cycle is involved with the production of serotonin and noradrenaline which are neurotransmitters implicated in anxiety, depression and other mental health conditions.

Where is it found?
Milk, eggs, rice, fortified breakfast cereals.

Vitamin B3 (also called: Niacin)
This helps to synthesise many vital bodily components such as neurones, other cells of the nervous system and some hormones. B3 deficiency is not common in the developed world but can occur where there is malnutrition as well as in people who have alcohol dependence. Tiredness and depression can, among other things, be symptoms of B3 deficiency.

Where is it found?
There are two forms of niacin – nicotinic acid and nicotinamide – both of which are found in food.
Meat, fish, wheat flour, maize flour, eggs, milk.

 Vitamin B5 (also called: Pantothenic acid)
This is necessary for the production of an essential compound called Co-enzyme A which is required all over the body for normal functioning including the synthesis of the neurotransmitter acetyl choline and of hormones such as steroids and melatonin. Fortunately B5 deficiency is rare in the developed world these days, but is serious when it occurs.

Where is it found?
Pantothenic acid is found in virtually all meat and vegetable foods. Good sources include:
Chicken, beef, potatoes (not crisps), avocados, porridge, tomatoes, kidney, eggs, broccoli, wholegrains (such as brown rice and wholemeal bread).
 
Vitamin B6 (also known as: Pyridoxine)
B6 is essential in energy metabolism, the methylation cycle (see under B2), and producing glutathione which is an antioxidant in the brain. Higher levels of vi­tamin B6 have been linked to a lower preva­lence of depression in adolescents, and low B6 levels can increases the risk and severity of depression in older adults. B6 deficiency may also be more prevalent in women taking the oral contraceptive pill

Vitamin B6 is found in a wide variety of foods including:
Pork, poultry (such as chicken or turkey), fish, bread, whole cereals, such as oatmeal, wheat germ and rice, eggs, vegetables, soya beans, peanuts, milk, potatoes, some fortified breakfast cereals.
 
Vitamin B9 (also known as: Folic Acid / Folate)
This is essential in the synthesis of serotonin, noradrenaline and dopamine, all neurotransmitters involved in mental health conditions such as depression. Folate deficiency or its milder version, insuf­ficiency, have been documented in people with mood disorders and may be related to illness severity. Vitamins B9 (Folate) and B12 are also important to ensure healthy red blood cells.

Some types of Folate supplements can improve response to treatment in people with depression and bipolar disorder. It is important to check this with your doctor because some people have 2 recessive genes for methylenetetrahydrofolate reductase which means they need a specific type of supplement.

Where is it found?
Folic acid is found in small amounts in many foods. Good sources include:
Broccoli, brussels sprouts, liver, spinach, asparagus, peas, chickpeas, brown rice, fortified breakfast cereals.

It is important not to take too much Folate as a supplement (no more than 1mg / day) as this can hide an underlying B12 deficiency which could then become serious.

Low levels can result from eating a poor diet or not being able to absorb the vitamins that are consumed. So older adults, vegetarians and people with digestive disorders such as coeliac disease or Crohn's disease may have trouble getting enough B-12. 

Women who are pregnant or wishing to conceive should take 0.4mg (400 microgram) of folic acid as a supplement daily until the 12th week of pregnancy, to help prevent defects of the baby’s central nervous system.

Vitamin B12
This is needed to produce monoamine neurotrans­mitters (such as serotonin, nor adrenaline and dopamine) and it also helps maintain myelin, the protective covering around some nerve cells. B12 deficiency can be seen in some people with depression and it may compromise response to antidepressant medication.  B12 deficiency has also been associated with irritability, agitation, psychosis, and obsessive symptoms. Low B12 lev­els and elevated homocysteine may also increase the risk of cognitive decline and Alzheimer’s disease.

Where is it found?
Meat, salmon, cod, milk, cheese, eggs, some fortified breakfast cereals.

Depression is a common but serious condition. It is hard to exactly work out its prevalence because estimates vary depending on the symptoms being measured. The UK’s National Institute for Health and Care Excellence (NICE) estimates that up to 1 in ten of us will suffer a depressive episode in our lifetime and that at any given time up to 14 % of people may be experiencing mixed depression and anxiety symptoms. Depression is even more likely to occur in people with long term physical illnesses such as diabetes (Anderson et al, Diabetes Care, June 2001) or in those who live with chronic pain.

Depression can look like different things: In some cultures, people may present with physical complaints rather than outright depression. This may also be true for some older adults.  Also, people who use drugs such as cannabis, or drink more than they should, may find they are masking underlying feelings of depression. Anxiety disorders, adjustment disorders, and persistent distress can all look like depression.

However it is important not to diagnose depression when it isn’t there because misdiagnosis can result in people being given the wrong medication, risking side effects. Sadness is an important part of life and automatically making it a medical condition takes away our opportunity to work through it and develop as individuals.

These questions may help you work out whether you might be suffering from depression rather than ordinary sadness:

1)       Do I still enjoy the things that are important to me?  If you have stopped finding pleasure in your usual pastimes or relationships and perhaps have stopped doing these things, this may be a sign of depression.

2)      Is my mood low?  People with depression may often (but not always) feel sad. This lasts for weeks or months, unlike distress which tends to pass quickly or comes and goes. Sometimes people with depression do not feel sad but experience more physical pain or feel emotionally numb.

3)      Has my sleep changed? Usually this will mean difficulty getting off to sleep or staying asleep. But sometimes people find the opposite happens and spend all day in bed, dozing or hiding away.

4)      What is my energy like?  Depression usually causes exhaustion and low energy so that people become tired easily. Sometimes this is noticeable to others, for example, by slowness of speech or activity. Also, people with depression can feel agitated. Anxiety and depression often exist together.

5)      Can I concentrate? Depression affects our ability to focus. If you are depressed you may find it hard to concentrate on a TV programme that you usually watch, or not be able to do your job like you used to.

6)      What is my appetite like? People with depression often lose their appetite and sometimes lose weight as a result. However other people may comfort eat and gain weight with depression.

7)      Do I look at myself with a sense of failure? Depression makes people see themselves in a negative way. They may find themselves thinking they have failed where others have succeeded. As depression gets worse, sufferers may feel as if they are a burden to others or feel a lot of guilt.

8)      Do I think about ending my life? One of the most difficult feelings that depression can bring up is that of ending one’s life. If you have noticed this it is vital that you seek help and support immediately.

If after reading this you think that you might have depression, please think seriously about getting help. Depression is very difficult to fight alone, but with the right help most people recover. In some cases, depression can occur for another reason such as an underactive thyroid gland or as a side effect of certain medications, so it is important to check this out with your doctor.

Places where you can get support immediately in the UK are:

The Samaritans:
http://www.samaritans.org/
Tel:  08457 90 90 90

NHS 111: http://www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/NHS-111.aspx
Tel: 111 (from UK landlines and mobiles)

But if it is less urgent, please arrange to see your doctor. 

As we move into the depths of winter, it is important to look after our immune systems, for our physical health as well as our emotional well-being. There is a well known link between viral illnesses like the ‘flu and mood changes (see, for example, Smith, A. Psychoneuroendocrinology, 2013 Jun; Vol. 38 (6), pp. 744-51). 

Here are some suggestions to help your body stay strong:

1)     Have a teetotal January

We all dabble with excess over Christmas but did you know that drinking too much can weaken your immune system, making your body an easier target for infection?  Just drinking a lot on one single occasion can make it harder to fight infections up to 24 hours later. For more information see http://www.niaaa.nih.gov/alcohol-health/alcohols-effects-body

2)     Quit smoking

If you smoke, quitting is the single best thing you can do for your immune system. Cigarette smoke contains toxic compounds like poly-aromatic hydrocarbons that weaken the immune system. This is one reason why smokers are more likely to get sick, as well as becoming vulnerable to autoimmune diseases such as rheumatoid arthritis and multiple sclerosis in the future. Give yourself a boost by resolving to quit. Read more at http://smokefree.gov/health-effects

3)     Try a multivitamin?

People over 65 or those on a restricted diet are more vulnerable to catching the ‘flu. One reason may be reduced amounts of essential nutrients caused by eating less or by getting used to a limited range of foods in the diet. If you think you may fall into either of these categories you may find a general multivitamin supplement helpful. Please check with your doctor or pharmacist first if you are not sure whether this is the right thing for you.

 4)     Follow the wisdom of Chinese medicine

This has been handed down for over 2000 years. This tells us to eat warm, cooked foods during the cold months. If we do this, our health in spring and summer will be better.

 5)     Immune boosters

Our immune systems are incredibly complex. Even though it is a nice idea, unfortunately it is way too simplistic to think of taking a single supplement to boost them, especially if we don’t explore the rest of our lifestyle and diet. Having said that, ancient herb lore considers Elderberry (Sambucus Nigra) a natural immune tonic. Some studies have shown that it can reduce the duration of ‘flu symptoms. (see http://umm.edu/health/medical/altmed/herb/elderberry for more details)
 
Unless you know what you are doing, it is best to buy this as a tincture or tablet because most parts of the plant are poisonous until cooked. 
Remember that herbal remedies are active compounds that can interact with other medicines you might be taking, so please check with your doctor if you are not sure.