Maxine Bigby Cunningham has battled major depression and anxiety for 20 years, but about five years ago, her symptoms intensified to the point that she could barely get out of bed, and she was so anxious she could hardly breathe — but only during certain months.
The Mount Washington resident, who leads mental wellness workshops and writes on the topic, had developed seasonal affective disorder (SAD), becoming increasingly depressed when the days get shorter.
Bigby Cunningham is one of an estimated 11 million people in the U.S. known to be suffering from SAD, though many practitioners believe more are undiagnosed. Treatments for the disorder vary, but one is garnering more medical attention this winter following a recent study led by researchers at the University of Vermont and published in the American Journal of Psychiatry.
Cognitive behavioral therapy (CBT), a type of psychotherapy focused on correcting distorted thinking and skewed beliefs, was shown to be more effective in the long term than light therapy, another common treatment for SAD. Of the 177 patients in the study, those treated with cognitive behavioral therapy had less recurrence and less severe symptoms over two winters than patients treated with light therapy, a practice that involves exposure to full-spectrum light to simulate the sun.
Kelly J. Rohan, the lead author in the study and a University of Vermont professsor, said cognitive behavioral therapy may be more effective in the long term because it teaches "skills to change the way a person responds to winter." The therapy "gives the person a sense of control over his [or] her SAD symptoms by virture of changing thinking styles and actions," she said. In comparison, light therapy suppresses symptoms only as long as treatment is continued.
Practitioners have been using cognitive behavioral therapy to treat SAD for decades, sometimes in combination with therapy or medication.
"But what's most exciting is now we know this therapy lasts a long time. So even if a person needs medication, they may not need to continue it for as long," said Kim Anderson, a psychologist at Sheppard Pratt Health System in Towson. She hopes the study findings will encourage people suffering from SAD to consider cognitive behavioral therapy before trying medications.
It also presents an alternative treatment for people who experience side effects from light therapy, according to Harry Brandt, chief of psychiatry at the University of Maryland St. Joseph Medical Center.
"It is important in that it highlights the need to look at different treatments. Some people have side effects from light therapy [such as jitteriness and headache]… and those people might do better with CBT. But many patients will end up on both and benefit," said Brandt.
To explain the term "cognitive behavioral therapy," Anderson breaks it down: "Behavior is what you do, like engage in pleasurable activities that give positive reinforcement. Cognition is tied to your automatic thoughts — what pops in your head through the day. We use CBT to … build on positive thoughts. In changing thoughts, you can change behaviors," she said. Though sometimes, she added, changing behavior first helps alter thinking, ultimately changing chemicals in the brain that affect mood.
The goal is to become aware of thought processes and work toward changing distorted thinking, replacing it with healthier thoughts.
Cognitive behavioral therapy sessions are very structured, each with a specific goal, and patients may have homework. If the goal is to deal with the urge to stay in bed all day, conversation will center around why it's hard to get out from under the blankets, and how to do it. Homework may be to go for a walk in the snow, or a drive with friends.
Bigby Cunningham had participated in cognitive behavioral therapy for years, but the focus changed when she developed SAD.
"Once I feel the days getting shorter … I have to deal with the fact that doing anything at all is overwhelming," she said. "So we focus on less topics because I don't have the energy and have a harder time getting the words out."
SAD typically takes hold from fall through winter and correlates with the days getting shorter. Common symptoms are a down mood, low energy and social withdrawal. People may have a diminished sex drive, anxiety, irritability and trouble concentrating, said Brandt.
Before she developed SAD, Bigby Cunningham was taking antidepressants and exercising about five times a week to try to shake her depression.
"It became not enough when SAD hit," she said. "I couldn't concentrate or follow basic instructions. I would boo-hoo often and did not know why. I had a heaviness in my chest that wouldn't move and an emptiness in my gut. It was like when I have lost a loved one, but now it's whenever there's little or no sun."
During cognitive behavioral therapy sessions, Bigby Cunningham's therapist asks her to pay special attention to the decisions she makes and why. But there's more to tackle this time of year, she said, recalling a blustery afternoon when she was in a jam-packed mall selling her books. Between her trouble concentrating and social anxiety, she became so overwhelmed that she lost her keys and car.
"Everyone suggested I went out the wrong door — the vending space coordinator, security and Baltimore police, who I called because I thought someone stole my car," she said, recalling that she worked herself into a major frenzy. "I thought that everybody was thinking something contrary to what I was positive I knew. And that they thought I was crazy."
It's this kind of skewed thinking the therapy helps correct. Through therapy, Bigby Cunningham recognized she'd jumped to a conclusion that her car had been stolen, then wouldn't consider the possibility that the others were right and she was mistaken out of embarrassment.
"[My therapist] asked, 'Were there a lot of people around? How did it make you feel? Why are you [selling books in a crowded mall in the winter] if you know it's not healthy for you?' This helps me recognize I am not thinking things through before acting," said Bigby Cunningham.
Holidays, especially, can intensify SAD, often because they trigger thoughts of family who may not be around — not to mention, "The holidays come and go before you know. Then you are back where you started, feeling empty in the middle of cold, dark winter," said Aharon Miller, a clinical professional counselor in private practice and at Sinai Hospital of LifeBridge Health in Baltimore.
Many people who struggle in the winter have depression year round, though less severe at other times. Mary Prendergast, a clinical professional counselor in Baltimore and Parkton, believes people who are worse in the winter have an advantage — at least from a treatment perspective.
"They have a frame of reference. You can get them to see they are not functioning as they normally would and to think about what they do when they are healthier," she said. "What would your typical weekend look like in the summer, when, say, you would be hiking or meeting friends? I would ask, 'What is stopping you now?'"
By working through the thought process, patients often begin to see differently, though it can take time — anywhere from four weeks to years, depending on whether the patient has other conditions, the severity of their symptoms and the frequency of therapy, said Prendergast, who suggests once or twice a week.
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"Ideally they should begin therapy in the spring or summer before SAD hits, because once the negative thought patterns begin, we have a disadvantage," he said.
For Bigby Cunningham, a combination of treatments seems to be working. Her business is developing well as she learns to do only what she can and better manage her anxiety. When she is not working, she's enjoying downtime with family and friends.
And accepting that she has this condition is helpful in coming to terms with the lifestyle changes she continues to make.