SAD and Chronic Pain - what treatment helps

Nobody likes the short, colder days of the winter season. If you are suffering from chronic pain it can be even more of a problem.

Seasonal Affective Disorder (SAD) is form of depression that occurs during a particular time of the year, typically the winter. There appears to be a relationship with a pattern of increased chronic pain symptoms and SAD leading researchers to suggest that there may be a biological reason the two are related.

What is Seasonal Affective Disorder (SAD)?

Features of SAD include being irritable, exhausted, distracted, and withdrawn. These are features common to many chronic pain suffers but in fact you may be dealing with something else not just an increase in you chronic pain. Add in low energy, weight gain and increased sleep the you have to think about the possibility of SAD.

Dr. Dominic Hegarty (Clinical Director, Pain Relief Ireland) recognises these features in some of this patients. “Many patients notice an increase in symptoms over the period November to February. Sometimes they link the increase in chronic pain with low energy or low mood and they can be quite frustrated with the impact time of the year can have on their well-being.

Who is at risk?

Estimates of the incidence of SAD in the general population suggests about 5% individuals experience SAD annually. The true value of SAD in those with chronic pain is unknown but given that 1 in 5 individuals have chronic pain there is likely to be a significant overlap. For example when you consider the number of individuals with fibromyalgia, chronic myofascial pain and chronic fatigue syndrome it is very easy to imagine it has a high impact in the those with chronic pain.

SAD is more common among young people, it is four times more common in women, is at a higher risk in those with a history (either personal or familial) of depression or bipolar disorder, as well as those who live far from the equator.8 Interestingly there is a summer version of SAD as well. This is characterized by restlessness, a decline in appetite, and insomnia.2

Alfred Lewy, M.D., Ph.D., an internationally recognized pioneer in the study of circadian (24-hour) rhythm disturbances and his colleagues in the Oregon Health and Science University (OHSU) Sleep and Mood Disorders Lab set out to test the hypothesis that circadian physiological rhythms become misaligned with the sleep/wake cycle during the short days of winter, causing some people to become depressed. Usually these rhythms track to the later dawn in winter, resulting in a circadian phase delay with respect to sleep similar to what happens flying westward. Some people appear to be tracking to the earlier dusk of winter, causing a similar amount of misalignment but in the phase-advance direction. Symptom severity in SAD patients correlated with the misalignment in either direction.

If an individual with a chronic pain condition, such as fibromyalgia, can attribute the increase in tiredness, the increase irritability or the altered mood and sleeping pattern to SAD it can be very reassuring that is not just their chronic pain but a separate condition...

What treatments help?

Dr. Hegarty says that firstly recognising the symptoms can be very important for an individual particularly if they struggle with chronic pain on a daily basis. “If an individual with a chronic pain condition, such as fibromyalgia, can attribute the increase in tiredness, the increase irritability or the altered mood and sleeping pattern to SAD it can be very reassuring that is not just their chronic pain but a separate condition”. Importantly, because you can treat SAD with some simple steps it is equally important not to ignore the change in symptoms.

There are several effective treatment options available:

Light Therapy (or Phototherapy)

For many, this is the first-line treatment for SAD. After waking up in the morning, patients sit 12-18 inches from a light box—an illuminated device that should emit 10,000 lux of strong white light and very little ultraviolet (UV) light—for 30-45 minute sessions. A two-week course of treatment is usually effective.9

Some individuals find that having a winter sunshine holiday is enough to offset the SAD.

Dr. Hegarty says that with all medication there are advantages and disadvantages and sometimes a balance has to be found that suits each individuals needs. Duloxetine, is an antidepressant included in the pharmacological class of serotonin-norepinephrine reuptake inhibitors approved for the treatment of major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain. There is now some evidence that it may be an effective treatment for mood spectrum disorders ( Frontiers Psychiatry 2019).

Other antidepressants are also used to treat SAD; popular options include a class of drugs known as Selective Serotonin Reuptake Inhibitors (SSRIs), particularly fluoxetine (Prozac) and bupropion (Wellbutrin).12 

It may be possible to use this style of medication to help an individual with chronic pain get over the seasonal issues but it may take a few weeks for the medication to help so it need to be considered in advance with you doctor.

Vitamin D

Vitamin D is produced by the body after exposure to the sun, therefore people tend to have lower vitamin D levels in the winter. Supplementation of this nutrient (either through foods or supplements) could help alleviate SAD symptoms.  It has also become easier to measure vitamin D levels.

There have not been many studies researching vitamin D’s effect on SAD, some researchers have found a link between low levels of vitamin D in the blood and depression. Low vitamin D levels have been reported in chronic pain patients including Fibromyalgia and chronic pain syndrome.

There has been some interesting recommendations such Stewart B. Leavitt, MA, PhD, writing in Practical Pain Management, who feels that a “vitamin D supplement may help patients cope with Chronic pain”. Dr. Hegarty supports this approach and would suggest either taking vitamin D as a single table or in conjunction with a multivitamin as a practical step we could all consider. Speaking with your pharmacist would help identify the best option for you.

Researchers have found that melatonin, a naturally occurring brain substance, can relieve the doldrums of winter depression, also known as seasonal affective disorder, or SAD. The study is publishing in the Proceedings of the National Academy of Science. The time and dose of the treatment is important to help individuals.

Cognitive Behavioural Therapy (CBT)

This form of talk therapy can help treat SAD. In CBT, trained clinicians encourage patients to challenge unhelpful thought patterns17 and become more active and engaged with others, as well as plan for future SAD episodes.

This form of psychotherapy involves the therapist working with the individual to help the depression sufferer identify and understand ways of thinking that may be obstacles to improving their mood, thereby increasing the ability of the person with seasonal affective disorder to alleviate symptoms. In CBT, trained clinicians encourage patients to challenge unhelpful thought patterns and become more active and engaged with others, as well as plan for future SAD episodes.

Physical Activity

Dr. Hegarty also recommends exercise. “Physical fitness lends us natural endorphins (pain-relieving hormones) that can help boost moods,” he says. In fact, a lack of exercise could be one reason for a possible link between chronic pain and SAD symptoms. Physical activity is recommended for the relief of many pains from lower back pain to fibromyalgia to arthritis.

With the long dark evenings “People tend to be more sedentary during the winter, and that can lead to feelings of low self-confidence and unhappiness”. In an English study with almost 2,500 people, respondents were most likely to experience pain in the winter.

There are many ways to be active even during the winter months: follow an exercise class online or on cable television, meet a friend for indoor tennis or a yoga class, incentivize yourself by setting up—and paying for—a gym membership. The importance of exercise can't be overstated. By adding physical activity to your treatment plan, you’ll help fight chronic pain and depressive symptoms at the same time.

SAD needs to be recognised and is a treatable condition and may explain the increase in pain during the long dark months of winter. You should discuss your symptoms with you doctor or pain physician and see what are the right options for you.

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