Influence of Timed Nutrient Diet on Depression and Light Sensitivity in Seasonal Affective Disorder

The role of affective temperaments as a factor of vulnerability to seasonal affective disorder

BACKGROUND

Growing evidence suggests the relevance of affective temperaments in the development of mood disorders. This study aims to assess their potential role as a vulnerability factor for seasonal affective disorder (SAD) and subsyndromal SAD (S-SAD) in a sample of young individuals without a history of clinical diagnosis.

METHODS

Eight hundred and forty-six university students were enrolled in a cross-sectional study. Participants were evaluated for exclusion and inclusion criteria and divided into Control, S-SAD, and SAD groups. They filled out two self-administered questionnaires to assess the degree of seasonality problems and the predominant type of affective temperaments, the Seasonal Pattern Assessment Questionnaire (SPAQ), and the Temperament Evaluation Instrument of Memphis, Pisa, Paris, and San Diego-Auto-questionnaire version scale (briefTEMPS-M version). We conducted a multinomial logistic regression model to explore the relationship between affective temperaments and seasonality.

RESULTS

Our results evidenced that cyclothymic [χ2 (2) = 33.486, p < 0.001] and anxious [χ2 (2) = 86.991, p < 0.001] temperaments were significant predictors in the model, suggesting that individuals with cyclothymic and anxious temperaments are at increased risk of developing SAD, due to heightened seasonal changes in mood and behavior. In contrast, people with hyperthymic temperament appear less susceptible to experiencing seasonal problems.

LIMITATIONS

The homogeneity of the sample; only retrospective self-reported data were considered; measures of temperament and seasonality were simultaneously assessed.

CONCLUSIONS

Understanding which affective temperaments may constitute a potential predisposing factor for vulnerability to seasonal changes can aid in better assessing SAD and predicting its outcome.

Lifestyle modification as intervention for seasonal affective disorder: A systematic review

Bright light therapy (BLT) and pharmacological therapies currently represent the first line treatments for patients with seasonal affective disorder (SAD). Lifestyle modifications offer a diverse field of additional intervention options. Since it is unclear, if lifestyle modifications are effective in SAD patients, this systematic review aims to synthesize the current evidence on their effectiveness and safety. We systematically searched for randomized controlled trials (RCTs) assessing lifestyle modifications (nutrition, exercise, staying outdoors, sleep, social aspects, mindfulness methods) in SAD patients. We defined the primary outcome as the post-therapeutic extent of depressive symptoms, measured by validated psychiatric symptom scales. Due to the insufficient number of studies and the high heterogeneity of the interventions we were not able to calculate a meta-analysis. We identified 6 studies from the following areas of lifestyle modification: diet, exercise, staying outdoors, sleep and music therapy. All studies showed improvements of depression scores in the intervention as well as in the control groups. The risk of bias was rated as high for all studies and the certainty of evidence was rated as very low. The results point towards the possible effectiveness of the interventions examined, but due to the small number of studies found, too small sample sizes and methodological limitations, we cannot draw a valid conclusion about the effectiveness of lifestyle-modifying measures in SAD patients. Larger, high-quality RCTs are needed to make evidence-based recommendations and thus to expand the range of therapeutic options for SAD.

Meal timing and its role in obesity and associated diseases

Meal timing emerges as a crucial factor influencing metabolic health that can be explained by the tight interaction between the endogenous circadian clock and metabolic homeostasis. Mistimed food intake, such as delayed or nighttime consumption, leads to desynchronization of the internal circadian clock and is associated with an increased risk for obesity and associated metabolic disturbances such as type 2 diabetes and cardiovascular diseases. Conversely, meal timing aligned with cellular rhythms can optimize the performance of tissues and organs. In this review, we provide an overview of the metabolic effects of meal timing and discuss the underlying mechanisms. Additionally, we explore factors influencing meal timing, including internal determinants such as chronotype and genetics, as well as external influences like social factors, cultural aspects, and work schedules. This review could contribute to defining meal-timing-based recommendations for public health initiatives and developing guidelines for effective lifestyle modifications targeting the prevention and treatment of obesity and associated metabolic diseases. Furthermore, it sheds light on crucial factors that must be considered in the design of future food timing intervention trials.

The Role of Diet, Eating Behavior, and Nutrition Intervention in Seasonal Affective Disorder: A Systematic Review

Background: Seasonal affective disorder (SAD) is a biological and mood disorder with a seasonal pattern. Dietary intervention and nutritional status have been reported to affect SAD severity. The objective of this study was to systematically review the evidence of associations between SAD and diet, eating behavior, and nutrition intervention. Methods: We performed a comprehensive search of MEDLINE, EMBASE, Web of Science, and Google Scholar from inception up to July 1, 2019. Studies that examined diet and eating behaviors in SAD patients and tests of nutrition interventions for SAD were included. Two independent investigators extracted data based on study designs, participants, outcomes, exposures, and association measures. Results: Eleven studies were included: six studies examined distinctive dietary patterns and eating behaviors in SAD patients and five studies explored the efficacy of nutrition interventions for SAD. Vegetarianism and alcoholism were associated with higher SAD prevalence, but normal alcohol intake was not correlated with SAD severity. Compared with non-clinical subjects, SAD patients tended to consume significantly larger dinners and more evening snacks during weekdays and weekends and exhibit a higher frequency of binge eating, external eating, and emotional eating. Additionally, compared to healthy controls, SAD patients presented more cravings for starch-rich food and food with high fiber. However, neither the ingestion of carbohydrate-loaded meals nor Vitamin D/B12 supplementation showed benefit for SAD. Conclusion: Studies suggest that SAD patients may exhibit distinctive diet preferences and eating behaviors, but no current nutrition intervention has demonstrated efficacy for ameliorating SAD symptoms. Further evidence is needed from randomized controlled trials with larger sample sizes and longer durations.

Electroretinography in psychiatry: A systematic literature review

This review aims to consolidate the available information on use of electroretinography as a diagnostic tool in psychiatry. The electroretinogram (ERG) has been found to have diagnostic utility in cocaine withdrawal (reduced light-adapted b-wave response), major depressive disorder (reduced contrast gain in pattern ERG), and schizophrenia (reduced a- and b-wave amplitudes). This review examines these findings as well as the applicability of ERG to substance use disorder, Alzheimer's disease, autism spectrum disorder, panic disorder, eating disorders, attention deficit hyperactivity disorder, and medication use. While there have been promising results, current research suffers from a lack of specificity. Further research that quantifies anomalies in ERG present in psychiatric illness is needed.

Heritability of the timing of food intake

BACKGROUND & AIMS

While environmental factors are presumed to be primary drivers of food timing, preliminary evidence suggests that genetics may be an additional determinant. The aim was to explore the relative contribution of genetics and environmental factors to variation in the timing of food intake in a Spanish twin population. Because chronotype, bedtime and wake time are related to food timing, covariance with food timing was further assessed.

METHODS

In this observational study, 53 pairs of adult (mean (SD) = 52 (6.03) years) female twins (28 monozygotic; 25 dizygotic) were recruited from the Murcia Twin Register. Zygosity was determined by DNA-testing. Timing of the three main meals of the day was assessed via 7-day dietary records, and the midpoint of food intake was computed by calculating the midpoint between breakfast and dinner times. Chronotype, bedtime and wake time were self-reported. Heritability of food timing and related traits were estimated by comparing monozygotic and dizygotic twin correlations and fitting genetic structural equation models to measured variables.

RESULTS

We observed genetic influences for food timing, with highest heritability for the midpoint of food intake (64%) in an overweight/obese population (BMI = 26.01 ± 3.77). Genetic factors contributed to a higher degree to the timing of breakfast (56%) than the timing of lunch (38%) or dinner (n.s.). Similarly, heritability estimates were larger in related behavioral traits earlier on in the day (i.e. wake time, (55%)), than those later on in the day (i.e. bedtime, (38%)). Bivariate analyses revealed a significant genetic overlap between food timing and bedtime and chronotype (rG between 0.78 and 0.91).

CONCLUSIONS

Genetic influences appear to account for a significant proportion of the variability in food timing, particularly breakfast. Thus, interventions related to food timing may be more effective when targeting afternoon/evening traits, such as lunch or dinner times. Furthermore, our data suggest shared genetic architecture underlying food timing and phenotypically related traits.

CLINICAL TRIAL

NCT03059576. https://clinicaltrials.gov/ct2/show/NCT03059576.

Depressive mood and circadian rhythms disturbances as outcomes of seasonal affective disorder treatment: A systematic review

BACKGROUND

The present systematic review was aimed at critically summarizing the evidence about interventions focused on circadian rhythms and mood symptoms in seasonal affective disorder (SAD).

METHODS

A systematic search of the electronic databases PUBMED, PsycINFO and Web of Science was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Original papers reporting data about the effects of treatments on both mood and circadian rhythms disturbances in SAD patients were considered for inclusion. The quality of the evidence provided by the eligible studies was assessed using the Revised Cochrane Risk of Bias Tool (RoB 2.0) and the Cochrane Risk of Bias in Non-Randomized Studies of Interventions Tool (ROBINS-I).

RESULTS

Forty papers were deemed eligible for the systematic review. The evidence of treatment outcomes referring to circadian disturbances was not robust. Despite this, bright light therapy (BLT) demonstrates to phase-advance delayed rhythms and to improve sleep-wake disorders. As for mood symptoms, both BLT and selective serotonin reuptake inhibitors (SSRIs) show evidence of efficacy. The possible connection between improvements of mood symptoms and changes in circadian outcomes seems controversial.

LIMITATIONS

The included studies presented considerable methodological heterogeneity, small sample sizes and non-optimal sample selection.

CONCLUSIONS

The effectiveness of BLT in depressive symptoms and circadian disturbances of SAD was outlined by the present systematic review. The evidence about other biological and pharmacological treatments, although promising, should be replicated. A multifactorial etiopathogenesis could explain the heterogeneous clinical presentations of SAD and the complex link between mood and circadian symptoms.

Implementing prevention of seasonal affective disorder from patients' and physicians' perspectives - a qualitative study

BACKGROUND

Seasonal affective disorder (SAD) is a seasonally recurrent type of major depression that has detrimental effects on patients' lives during winter. Little is known about how it affects patients during summer and about patients' and physicians' perspectives on preventive SAD treatment. The aim of our study was to explore how SAD patients experience summers, what type of preventive treatment patients implement, which preventive treatment methods, if any, physicians recommend, and what factors facilitate or hinder implementation/recommendation of SAD prevention.

METHODS

We conducted 15 semi-structured interviews, ten with adult patients with a history of SAD and five with physicians. Transcripts were analyzed by two researchers using an inductive thematic analysis approach.

RESULTS

One group of patients was able to enjoy summer and ignore thoughts of the upcoming winter. The other group feared the impending depressive episode in winter, and this fear negatively impacted these patients' well-being during the summer. Preventive treatment was a relevant issue for all patients, and all but one person implemented SAD prevention during summer. We identified six factors that influenced patient use of preventive treatment of SAD. Four factors occur on an individual level (knowledge about disease and preventive treatment options, experience with treatment in acute phase, acceptability of intervention, willingness to take responsibility for oneself), one on an interpersonal level (social and work environment), and one on a structural level (healthcare system). All psychiatrists recommended some kind of preventive intervention, most commonly, lifestyle changes. Four factors influenced psychiatrists in recommending prevention of SAD (patient expectations, disease history and stability, risk/benefit ratio, lack of evidence).

CONCLUSIONS

Success in the implementation of SAD prevention does not solely depend on the willingness of the patients, but is also influenced by external factors. Raising awareness of SAD among general practitioners and low-level access to mental-health support could help patients find appropriate help sooner. To better guide the optimal treatment choice, comparative effectiveness research on treatments to prevent a new onset in patients with a history of SAD and clinical practice guidelines on SAD are needed.

Prevention of seasonal affective disorder in daily clinical practice: results of a survey in German-speaking countries

BACKGROUND

Seasonal affective disorder (SAD) is a seasonally recurrent type of major depression. This predictable aspect makes it promising for preventive treatment. However, evidence for the efficacy and harm of preventive treatment of SAD is scarce, as are recommendations from clinical practice guidelines. The aim of this study was to assess the current use of preventive treatment of SAD in clinical practice in German-speaking countries for the first time.

METHODS

We conducted a postal and web-based survey sent to the heads of all psychiatric institutions listed in the inventory "Deutsches Krankenhaus Adressbuch, 2015" that contains all psychiatric hospitals in Germany, Austria, and Switzerland.

RESULTS

One hundred institutions (out of 533 institutions, 19%), which treated in total more than 3100 SAD patients in the years 2014/2015, responded. Of those, 81 reported recommending preventive treatment to patients with a history of SAD. There was no consensus on the optimal starting point for preventive treatment. Most of the institutions that implemented prevention of SAD, recommended lifestyle changes (85%), antidepressants (84%), psychotherapy (73%), and light therapy (72%) to their patients. The situation was similar in northern and southern regions.

CONCLUSIONS

Most hospitals recommended the use of preventive treatment to SAD patients, although evidence on efficacy and harm is limited. A wide variety of interventions were recommended, although guidelines only include recommendations for acute treatment. To assist psychiatrists and patients in future decision making, controlled studies on preventive treatment for SAD that compare different interventions with one another are needed.

Dawn simulation vs. bright light in seasonal affective disorder: Treatment effects and subjective preference

BACKGROUND

Studies comparing the efficacy of dawn simulation to conventional bright light for the treatment of seasonal affective disorder (in parallel groups) have yielded conflicting results. This crossover study investigated treatment outcomes and long-term treatment preference.

METHODS

Forty winter depressives were treated for a week with bright light (4.300lx for 30-45min shortly after awakening) or dawn simulation (gradually increasing light during the last 30min of sleep achieving 100lx before alarm beep, with the dawn simulator placed closer to the open eyes for a further 15min: 250lx). The depression level was self-rated using SIGH-SAD-SR.

RESULTS

Depression scores reduced similarly following bright light and dawn simulation: for 43.8% and 42.2% (medians), respectively; efficacy ratio was 23:17. The preference was also similar (21:19). Among those who preferred bright light, the most common reason was that they perceived the bright light to be more effective (19/21; it was more effective, p=0.0096; this subgroup tended to have more severe depression) and ease of use (6/21). Among those who preferred the dawn simulator, the reasons were a more "natural" action (9/19), device compactness and/or time-saving (10/19) and in 4 cases where bright light caused eyestrain.

LIMITATIONS

Not overhead naturalistic light for dawn simulation, self-rating of depression.

CONCLUSIONS

Dawn simulation is similarly effective to bright light in the treatment of winter depression. Patients with more severe depression tended to report greater improvement with bright light; in such cases, this would outweigh the non-clinical advantages of dawn simulation.

Do restless legs syndrome (RLS) and periodic limb movements of sleep (PLMS) play a role in nocturnal hypertension and increased cardiovascular risk of renally impaired patients?

Hypertension can cause or promote renal failure and is related to cardiovascular mortality, the major cause of death in patients with renal impairment. Changes in the circadian BP pattern, particularly the blunting or reversal of the nocturnal decline in BP, are common in chronic renal failure. These changes in turn are among the major determinants of left ventricular hypertrophy. Using a chronobiological approach, it is possible to obtain better insight into the reciprocal relationship between hypertension, renal disease, and increased cardiovascular risk of renal patients. Disruption of the normal circadian rhythm of rest/activity may be hypothesized to underlie the high cardiovascular morbidity and mortality of such patients. Epidemiological studies reveal that hemodialysis patients experience poor subjective sleep quality and insomnia and, in comparison to healthy persons, are more likely to show shorter sleep duration and lower sleep efficiency. Sleep apnea may be present and is usually investigated in these patients; however, the prevalence of restless legs syndrome (RLS), which is high in dialysis patients and which has been associated with increased risk for cardiovascular disease in the general population, could also play a role in the pathogenesis of sleep-time hypertension in renal patients. Careful assessment of sleep quality, in particular, diagnostic screening for RLS and periodic limb movements (PLM) in renal patients, is highly recommended. In renal failure, attention to sleep quality and related perturbations of the sleep/wake cycle may help prevent the occurrence and progression of cardiovascular disease.

An overview of seasonal affective disorder and its treatment options

Seasonal affective disorder (SAD) is defined as a history of major depressive episodes that recur regularly at a particular time of year. Depending on the diagnostic instruments and criteria available, the reported prevalence (1%-10%) varies. Neurotransmitter abnormalities have been implicated in the pathophysiology, but they do not necessarily explain the seasonal pattern or the known chronobiological abnormalities in SAD compared with nonseasonal depression. Circadian rhythm abnormalies have been hypothesized to account for these aspects of SAD, and they provide a rationale for the therapeutic use of light therapy. Family history, twin, and molecular genetics studies suggest that hereditary factors are also involved. Light therapy and antidepressant medication are effective treatment options, with limited evidence for the efficacy of psychotherapy. Some studies demonstrate that narrow-band short wavelength "blue" light, naturalistic dawn simulation, and high-density negative air ionization are effective. Patients should be informed of the benefits of diet and exercise. Light therapy should be clinically monitored in the same manner, as it is done for other antidepressant treatments.

Report of two double-blind randomized placebo-controlled pilot studies of a carbohydrate-rich nutrient mixture for treatment of seasonal affective disorder (SAD)

We investigated a carbohydrate-rich nutrient-drink mix for treatment of seasonal affective disorder (SAD). This mixture may contribute to brain serotonin synthesis, potentially exerting an antidepressant effect and controlling carbohydrate cravings. Two successive double-blind placebo-controlled studies were performed. In Study 1, 18 subjects (50% women; mean age 43 +/- 15 years) with SCID-diagnosed SAD were randomized to 12 days of twice daily carbohydrate beverage (CHO) containing mixed starches, or a placebo beverage (PRO) containing the CHO mix plus casein protein to dampen serotonin synthesis. Following a 2-day washout, subjects were crossed over to the other treatment for 12 days. In Study 2, 32 subjects (63% women; mean age 46 +/- 14 years) with SCID-diagnosed SAD were randomized to 21 days of CHO or PRO. Efficacy in both studies was determined by the first 17 items of the Hamilton Depression Rating Scale (HAM-D-28), an appetite questionnaire, and regular weighing. In Study 1, response rates were 50% for both groups. Remission rates favored CHO (50% vs. 38%), as did the decrease in the HAM-D-17 score, but differences were nonsignificant. In Study 2, response rates were 71% for CHO and 76% for PRO, and remission rates were 71% for each group. Both treatment groups experienced significant improvement in HAM-D-17 scores within 1 week of treatment, which continued through the entire study period. Weight change did not differ significantly between treatment groups in either study. The drink mix was well tolerated and treatment adherence was high. Both the active and placebo intervention were effective in alleviating symptoms of SAD. Replication studies in larger samples appear warranted.

Short day-length increases sucrose consumption and adiposity in rats fed a high-fat diet

BACKGROUND

Photoperiod, i.e., the relative day-length per 24h, may modulate the metabolic responses to high-fat diet (HFD) and sucrose consumption.

METHODS

To test this hypothesis, hormonal changes, fat accretion and sucrose intake were measured in rats exposed to short- or long-day for 4 weeks and fed with a standard high-carbohydrate low-fat pelleted diet (high-carbohydrate diet (HCD)) or a high-fat, medium-carbohydrate pelleted diet (HFD), with or without free access to 10% sucrose solution in addition to water available ad libitum.

RESULTS

Plasma leptin and adiposity index, defined as epididymal white fat expressed as percentage of body mass, were markedly increased only in HFD-fed animals drinking sucrose under short, but not long, photoperiods. Voluntary ingestion of sucrose under short days was greater in HFD rats compared with HCD animals over the experiment, while a trend for the opposite effect was visible under long days. Total energy intake was not changed overall, as rats proportionally decreased chow intake when they drank sucrose. A noteworthy exception was the HFD group with sucrose access under short days that significantly increased their total calorie intake. Fasting blood glucose was generally unaltered, except for an increase in HFD-fed animals drinking sucrose under long days compared to control animals, suggesting a decrease in glucose tolerance. Insulin resistance was not yet affected by nutritional or photoperiodic conditions after 4 experimental weeks.

CONCLUSIONS

Even if photoperiod cannot be considered as an obesogenic environmental factor per se, the metabolic effects resulting from the combination of high-fat feeding and voluntary intake of sucrose were dependent on day-length. Exposure to short days triggers a larger increase of sucrose ingestion and hyperleptinemia in rats fed with HFD compared to the control diet. Considering that the cardinal symptoms of winter depression include carbohydrate craving and increased adiposity, the present data provide an experimental basis for developing new animal models of seasonal affective disorder.