Making it Through Winter: Seasonal Affective Disorder and Winter Mental Health Tips

Preston: [00:00:00] Hello, it is us from the past talking to you in the future. But besides the fact, I imagine my future self listening to this got some really good gifts for Christmas, which is my question to you. What are some of your favorite gifts and how do you approach gift giving? 

Margaret: Okay, those are two questions. Let's start with favorite gifts.

I, my sister is like, my older sister is a really good gift giver. And so one thing I got, I turned 30 a couple weeks ago and My sister took, like, got all of my, my one niece and my seven nephews to take pictures holding like birthday signs for me and then sent me a photo album with all of them that are like, [00:01:00] happy birthday Aunt Mag, um, and then like a recipe book that looks like the one that we grew up with in childhood.

Um, so I thought that was really great. Maybe not the best one of my whole life, but it's top of mind and it was like really, really sweet. So something 

Preston: that was thoughtful and sentimental has a lot of value to you. 

Margaret: Yeah, and I like, it's like a Rifle Paper Co. recipe book. So it's like you add pages and I like to like paint in recipes and like as I like come to like edit them and stuff.

And so it's, it's fun. It's very sentimental, but yes, yeah. So I don't know. That was a good recent gift. What about you? 

Preston: I think one of the best recent gifts I got was a, um, yes, outside of your friendship, which was gift wrapped for my birthday, um, I got like a, a litter box concealer or like a litter box in, in housement.

So you know how like litter boxes are ugly and they smell, so you can get these like almost like aesthetic little [00:02:00] houses to put the box in, so it kind of fits in with the vibe of your furniture. And what is your vibe for your litter box? It's, it's like boho, 

Margaret: rattan. It's farmhouse chic. 

Preston: No, it's not farmhouse, we detest farmhouse.

You're 

Margaret: kind of farmhouse chic. Just kidding, you're not, you're like mid century modern. 

Preston: Yeah, I'm mid century modern boho, a little bit of organic modern. Anyways, I, like, The person who got me the gift, um, it was my ex girlfriend, my girlfriend at the time. She, she was like, I know that you just get like frustrated if something doesn't fit your aesthetic, your vibe.

So, she's like, I'm just going to find something and like relieve that. And so, it was really thoughtful because I was just, I didn't even like know that was an option for litter boxes. I I was just like, I'm cursed. I'm like stuck with this ugly thing. And she was like, surprised. Now it just looks like a box in the corner.

There could be anything in there. Like, maybe it's a, maybe it's a bunch of roses, but it's just cat poop. But you don't know by looking at it. 

Margaret: How are the cats doing at [00:03:00] sharing that space? 

Preston: Oh, um, pretty well. They don't, they don't go at the same time. I don't have cats. I'm 

Margaret: allergic to cats. Don't know about their life cycles.

Preston: Well, well, since, since I now know how to approach it, I got a couple more aesthetic hidden litter boxes in there. How many litter boxes 

Margaret: do you have in here? 

Preston: I have, I have two. So yeah, these losers, you're supposed to have one more litter box in the amount of cats you have. Oh, I should have three, but we're functioning okay with two.

Margaret: I'm going to report you to the Sarah McLoughlin, or whatever. 

Preston: National Cat Association. I'm putting that right now. I'm auditing myself. No, I swear they're happy. Look at them. They're sleeping on my chair right now. They're cute. They're calm. Yeah, they're friends. It's because of the ample amount of litter boxes they have.

Margaret: Can we ask the question of what is the worst gift you've ever gotten? I don't know. I don't know, is that rude? Is that rude chat? The person who got mine knows it and it's because my mom, shout out to my mom, love you, uh, [00:04:00] but it was a bad gift. 

Preston: I want to hear it. 

Margaret: So, I was eight, this is a trauma, is it a trauma?

I'm kidding, it's not a trauma, but, um, I was eight, and, you know, eight year old girls, I had normal eight year old girl normative, eight year old girl interest, like I liked coloring, I like, liked going to limited too, I liked Disney, like, da da da My mom got me a game, and I open it and I go, what is this?

And it looks like a sort of, like, primordial, like, bop it. And it actually is not a game, it's just a multiplying and division sort of calculator thing, that is supposed to look like a game, but is really just a long division and multiplication. Like an 

Preston: abacus or something? 

Margaret: Yeah, but like kind of technological and, and bright colors.

And I looked up at her and I was 8 years old and I just looked at my mom and goes, why would you, why would you get this to me? 

Preston: You're using your therapeutic language. You're like, [00:05:00] I just want to understand your thought process. 

Margaret: I just want, can you put me in your mind? Like what, what, what's your frame of mind for an eight year old right now?

Preston: I was going through your mind when you got me this, this like medieval abacus. 

Margaret: Well, that would have been cooler. If it was an abacus, it was like a, it was literally like you like twisted it and had to like hit things when you got the right number and try and like finish the most, and I was good at math, so it wasn't like a you need to improve Maggie, it was like she likes that, she likes those little yellow plastic things where you like would have a string, did you ever do this?

Did you do this in school? 

Preston: No, I don't know what you're talking about. There'd 

Margaret: be like numbers and you'd get like a little piece of plastic and have like a red string. Editors, can we put a picture of one of these up here if you know what I'm talking about? And you would like be timed and you'd have to like wrap the string around it and match like the number times something and you would get to the end of it.

Okay, maybe I did deserve 

Preston: flashcards. Maybe I 

Margaret: deserve the calculator Bop It for the amount of that punch. And I did not 

Preston: get flashcards. I would say the, um, I'm gonna go, I'm gonna make fun of my sister on this, and this isn't a gift I got, but it's a gift my mom [00:06:00] got. I think it was the worst gift probably we've, that's ever been given in our family, but it was really funny.

So, um, my mom was paralyzed in an accident in high school. She, um, she was hit, um, while cycling. So, she's paralyzed from the waist down. We're about three years out of the accident. So, like, we've adjusted to life around the household with her being paraplegic and she was always a doer. Like, she was, she was biking and doing these active things.

So, Heidi, my older sister goes, I want to give that back to her. And she's like, I want to give her the gift of freedom and that was interpreted by a wetsuit, which was like skin tight and like Arctic qualified and she was like, see, now you can go swimming in the lake with this wetsuit and my mom can't, she doesn't have any control, volitional control of her legs, so putting, trying to put a paraplegic leg in a wetsuit is like trying to play pool with a rope.

You know what I mean? And so, so [00:07:00] my, my mom opens the gift and sees, she sees the wetsuit and she, she just starts laughing. She doesn't even finish, she just starts laughing. We're like, mom, what's in the gift? What's in the gift? And Heidi's like, Heidi's like, it's freedom, mom. I've got your freedom. And then the mom starts laughing.

And then my little sister and I go down, and Heidi starts getting mad, and she leaves and starts crying. She's like, F you guys! In one word! This, this, what's.

Margaret: How old 

Preston: was your sister at 

Margaret: that time? 

Preston: She was like, oh gosh, she was like 19 or 20. So, Heidi is so, I think quixotic is the word I use. She is so optimistic and we call it like, um, uh, heidelism. [00:08:00] Is the word I came up with. Yeah, she's being like idealistic. And so she, she takes her looks with this because the thing is, like, Heidi's super real idealistic and she's real optimistic.

And sometimes she crashes and burns like this, but then sometimes she pulls off like The impossible. Like, she, so she's a care doctor and she created a new residency spot for her, a new fellowship spot for herself because she was like, I want to do this. And then, and then was like super optimistic and everyone was like, Heidi, I don't know if that's going to work out.

And then all of a sudden, like, Out of the ether, she creates a job for herself. So, shout out to Heidi. Shout out freedom. Sometimes you win, sometimes you don't. Can we 

Margaret: put the eagle sound in here? Yeah. So, 

Preston: now that we're done with gift giving, I want to kind of move into what we're actually talking about today.

Which is, yeah. 

Margaret: Now that we've delighted you with our mirth and our childlike whimsy. Time for 

Preston: the misery part. It's 

Margaret: time, yeah, it's time for balance. 

Preston: So, I, [00:09:00] my birthday is the second week of January, which is something I have to look forward to, but these next two weeks are dreaded. I just remember, I come back from school, and the days are dark, you're kind of dreading because the break is over and you're dealing with another semester, and it's like you go to school in the dark and you come back in the dark.

And it's just such a slog. 

Margaret: I feel like the worst January, February. I don't know if it was the worst, but the reason I have TikTok is because of intern year, January, February in Boston, it was like, I was on my medicine half of the year for psych and would get to the hospital at 6. and wouldn't leave till 7 and just didn't see the sun, just Just me, me and the moon were really vibing those two months and the depression made me start writing on TikTok as like, here's something for me to do.

Preston: Yeah, it's like, the sun is like your roommate that you never see because you guys work different jobs. You're like, bro. Just a 

Margaret: flighty minx during this time of the year. 

Preston: And so [00:10:00] it turns out that there's a very specific disorder that happens. 

Margaret: Yes. Based 

Preston: on these time movements, which is what the episode is about today.

That's seasonal affective disorder. Or 

Margaret: SAD. 

Preston: Yeah, familiarly seasonal depression. 

Margaret: Winter blues. 

Preston: So, yeah, I guess winter blues could be a subset of it. So, Margaret, I understand that you being inclined with Stregonona fall and all the things that we do to ward off the seasonal infection disorder, I was curious what you dug up as far as the social and political context of my winter blues.

Margaret: Yes. So, I think. We'll divide this two ways. Well, I'll say a couple sentences on what we define it as psychiatrists and the DSM 5. Um, and then bigger than that, because I think people are actually pretty familiar with, a lot of people are familiar with what seasonal depression is, but talk about what we see online and kind of the last five or ten years and just like the pop culture [00:11:00] slash like pop health experience of this and how people interact with it.

Um, so in the DSM 5 or the What is it? The manual? Diagnostic and Statistical Manual. What does the statistical stand for in that? There are statistics in it. There 

Preston: are statistics. If you thumb through it, there are statistics. There 

Margaret: are statistics, that's true. That's so true, but we don't put that in every book.

Like, anyway. I don't know why it 

Preston: got its spot. 

Margaret: But in the DSM 5, it is a subset of the manual. Like major depressive disorders or depressive disorders in general. Um, so a lot of this DSM 

Preston: 5 text reviews, text revised TR. Yeah, yeah. Thank you. 

Margaret: TR, I think it's also, I think it might be in the ICD 10 as it's own separate thing, but I did not review enough to know that and I don't use the ICD 10 or 11.

Yeah, we, we American Eagle sound again, get out of 

Preston: here, snow med, 

Margaret: but so a lot of the ways we [00:12:00] describe it are very, because of this, very similar to the ways that we describe depression in other settings. So, as we said before, in the podcast, and as all psychiatrists say, when they memorize this or med students, the Siggy caps of it all, which is sadness, loss of interest or anhedonia guilt.

Um, decrease in energy and like fatigue and then concentration, appetite, psychomotor slowing and sleep, I say, and then suicidality is its own thing outside of this. But so basically it's a kind of depression that we think about. Impacted by the seasons of the year and so we classically think of it as during the months like starting well We were just talking about starting in October through March So one thing like when it gets colder the days get shorter and there's less exposure to the Sun as well as harsher weather although I'm curious Preston what you'll have to say about the weather versus The sun exposure, um, in terms of the etiology.

Um, but that it can happen in the summer as well. So it's classically during like [00:13:00] winter, shorter light months, but I think there's an expanding definition of seasonal effective as being able to be basically impact from seasonal changes in the amount of light exposure, not just in a reduction, but also for some people in the summer or spring.

Um, and so, um, That's kind of a general clinical view of it kind of for shorthand We'll think of it as like depression that happens mainly in the winter though can happen at other times Within it's important to remember 

Preston: that like everything in psychiatry. These are basically a syndromes that we see So these are just symptoms that travel in space together And we observe that these symptoms travel in space along with some other phenomenon.

We know that they're linked somehow so just like We know chronologically that it's can can reliably start at a certain change of seasons and will also be relieved by that certain change of seasons and that's kind of all we've used to to guide [00:14:00] this gate, this naming organization basically. 

Margaret: The other thing the DSM says is it has to basically happen for more seasons than not.

I don't know how you would measure that necessarily, but like it has to happen like sort of year over year in adulthood. Like it's we usually don't diagnose if you like. Because, like, if you just have it during one winter, but don't have it other winters before, or don't have it after, we would less Categorize it as that.

That might be a depressive episode, but it might not be seasonally mitigated. Um, so it's greater than two. You have one 

Preston: dot in time, you can't draw a line between anything. You need two lines to draw a dot. 

Margaret: So true, Bessie. 

Preston: Look at that. There's our line. Now you can 

Margaret: draw it. Psychiatry loves making things in twos, like two years, two weeks, two months.

Especially when it comes to depression. So, okay, so that's a general clinical [00:15:00] overview. Um, I guess one thing I want to say about that is the prevalence, according to the APA website, is 5 percent of adults in the U. S. may experience seasonal depression. Um, and that that time period is about 40 percent of the year on average, especially if it's like in this winter timeline, um, the other clinical, 

Preston: it's about 5%.

A lot of people. 

Margaret: Yeah. And if you think about 5%, that's about 1 in 

Preston: 20. So, yeah, 

Margaret: yeah. Which kind of, maybe because I live in Boston, I'm like, I feel like more people have it. 

Preston: Well, yeah, because I'm here in Texas where it's not too often. So for every person in Texas, that's not That's not having seasonal depression.

There's five angry people at Dunkin Donuts in Massachusetts. Yeah, it's half the bus 

Margaret: where you guys are. Um, the other thing I was just going to say is that is this might be a little bit in the weeds. If I think it's interesting to clinicians, maybe interesting to people who are not diagnosing, but thinking about exacerbations of mood [00:16:00] disorders, or in this case depression versus something existing on its own.

So we wouldn't necessarily call it. I think there are times you might say if someone has a like really mild depression the rest of the year and then in the winter they have really, really severe depression, you still may call that part like mediated by like seasonal affective disorder, but in general, we think about them in a not pure world where we didn't just know things by syndromes is almost separate.

So you would almost say like their major depressive disorder worsens in the winter. But again, there's some intermix between that. The thing it reminds me of is like, When we talk about, like, PMDD versus, like, a PME, which is a premenstrual exacerbation, so winter can worsen people's depression who have depression all the time, and PMDD and PME, it's like premenstrual or menstrual symptoms can worsen Any mental health condition during that time because it's physiologically stressful.

So, I just say that to say that there's kind [00:17:00] of this difference in the sort of ideal diagnostic world in reality. I don't know that that's super meaningful outside of like maybe you increase your dose of antidepressants before the winter or something. 

Preston: Yeah, I run into the same problem with like a superimposed adjustment disorder on an existing mood situation.

Like someone is chronically depressed and they're on medication, but now their symptoms are worsening because they're going through a divorce. Well, do you treat this as just like a separate thing or do you see it as this divorce is an exacerbation of their mood disorder, so therefore you should adjust medication?

I think it's always been kind of hard for me to navigate those and I end up almost like, Retreating from the DSM and just kind of saying like, okay, what does my gut say? Because I feel like this is where our ability to categorize things starts to fail us a little bit. Yeah, no, it's really time for the vibe check.

Margaret: What are the vibes right now? 

Preston: What do you want to do? You're in charge now. 

Margaret: You're the doctor. Um, but so, [00:18:00] so that's kind of clinically what we're talking about. Um, I think it's been interesting the last 5 to 10 years, as Preston mentioned, Streganone, a fall of it all, but last year and now this year again, I have written in this time period about getting ready for Daylight Savings Time just because what I have found both In real life, here in New England and then in the Midwest where I grew up and trained for med school, there's real, but more honestly anecdotally on TikTok from like the people who follow me, is how much dread people have for winter, um, and just that the depression worsens, their mental health worsens, and sometimes not even like clinically, like, That just there's a really big feeling of like this is going to be a really really hard time of year And I think there's a number of reasons for that some of which are neurobiological that you'll talk about that impact everyone even if they are Quote unquote subclinical or don't have seasonal depression.

So the things I've loved reading into has been Obviously, we will talk about like medications and SSRIs and [00:19:00] Lobutrin, um, as well as like therapy or sleep kind of behavioral stuff, but thinking about ways to help people control what they can control during cold weather when they're very much like away from the sun, away from social gatherings, maybe, Um, isolating and feeling kind of cooped up because I think that that can be a big part and reducing exercise if there are people who exercise outdoors.

Preston: Yeah, I mean, we all have this relationship with our environment and that's dynamic as the seasons change. So ironically for me, um, I go out less in the summertime because it's so hot here. So, community shrinks, you work out less. And you spend more time around like artificial light, so anything that's gonna be to trigger like how you feel almost like a psychotherapeutically about the environment that you're in is going to affect all of that.[00:20:00] 

And some people frame it differently. 

Margaret: Yeah, I think we will talk about a little bit more on ways maybe we frame different seasons or things, um, but I wonder if, if you have any experience, I'm curious about like in Texas. Being where you are, I know you haven't been there always, but like, does, do you see seasonal affective disorder, or like, does it look like it happens in the summer, or like, is it still with like, cause the day is still short in there.

Preston: Yeah, so the days, the days do shorten and actually we have the luxury here of it getting annoyingly cold in January and still being unbelievably hot in the summer. So in the summer, I don't know if I've, I've classified this as seasonal affective disorder because a lot of it presents more as like irritability and anger, but there is an established connection between increased temperature and irritability.

Yeah. Yeah. 

Margaret: Yeah. And so 

Preston: that's actually, like, I'll see a lot more, like, [00:21:00] anxiety and frustration around, like, the heat because it's been two weeks where the temperature hasn't dipped below 100 degrees. Like, you go out at 11pm and it's 95 degrees. And I feel, I'm just like, I

Margaret: don't want to go for a run, 

Preston: I'm like, why is it so hot? Yeah, San Antonio is like, 

Margaret: The review paper I read actually mentioned what you're saying too of like that looking less like a melancholic neurovegetative depression as seasonal effective and more like an irritability anxiety, like anxiety, depression, whatever.

Preston: Yeah, it's funny because San Antonio actually is, um, I think we're number one in Texas for road rage incidents, and I wonder, you know how we look at like latitude for seasonal affective disorder? I wonder if you could do the same thing for like heat index of a city and their road rage. 

Margaret: Honestly, probably.

Probably. 

Preston: I think we'll know what we find if we investigate that. 

Margaret: NIMH. [00:22:00] Yeah, and Claw Preston, he's got some ideas. 

Preston: Phineas, I know what we're going to do today. 

Margaret: Um, yeah, it's, it's interesting to think about. So you feel like in winter, there's less of a, like, patience with depression because the winter there is, I don't know, sometimes though I think of winter and like these, like, southern places where it's just like everything's concrete and there aren't leaves on, do you keep your leaves?

No, so it's just like ugly and weird and rainy and that versus like here, maybe it'll snow. And I feel like that's kind of like a vibe to me. That's kind of a vibe. I also feel like there's a big part of this of like where you were like raised for the first like, you know, 18 years of your life and your tolerance or norm norming of like weather.

So like if you grow up around snow, 

Preston: the idyllic snow covered landscape really works for me. 

Margaret: Yeah, yeah. Whereas I feel like my friends from like California or who were raised like in the South [00:23:00] are like, when it's like 55 degrees here, they're like, how are you not wearing a coat to me? So, 

Preston: I feel like that's also part of it.

That cool kid from high school was like, I'm not even cold guys, I didn't even notice. Yeah, I'm wearing flip flops and basketball 

Margaret: shorts. 

Preston: It was cold out? It 

Margaret: was cold, I didn't know, I couldn't feel it, I couldn't feel it through my flip flops. So, I think that, I wonder what like your experience too is like.

I guess in Texas it's different, but I think up here there is a lot of like real fear and anxiety going into the season, like when daylight savings time happened, um, my like patients are worried about it in clinic 

Preston: and 

Margaret: they like tell me, Even if they don't have like a pattern of it. 

Preston: Yeah. I don't see too much of like that anticipatory anxiety about winter here.

We have it for, we do have it for summer and we have it for like our allergy season. So there are like certain environmental cues that we get hyped up [00:24:00] for, concerned about, but not, I don't, I haven't seen it the same in winter. Granted this is my only, my second winter here. 

Margaret: That's 

Preston: fair. That's fair. 

Margaret: I, so that's, that's most of the clinical kind of stuff, thinking about diagnosing.

Um, and thinking about it, before we talk about treatments, I think we should take a break and then you can talk to us a little bit about the neurobiology of this because I think it's fascinating and also a little, I don't want to say, it's not controversial, but it's like there's, I don't know, I think there's unsolved, like everything in psychiatry, unsolved questions.

Preston: Yeah, so we have a lot, there's like a bunch of cool facts, fun biochemistry, and then a lot of unsatisfying conclusions that we can make from it. 

Margaret: Are we going to talk about vitamin D? 

Preston: I didn't have any plans to talk about vitamin D, but we can. 

Margaret: I want to talk about it because a paper came out, not, a paper came out over the summer from the Endocrine Society on being like, uh oh, we're going to Vitamin D, question mark, I'll talk about it, it's a controversy, sort of related to this.

Okay, when we come back, 

Preston: vitamin D and the [00:25:00] neurobiology. Okay.

Margaret: Alright Preston, teach us about neurobiology. You 

Preston: make me sound so smart when you say that, and I'm like intimidated, I'm like, I don't know if I'm going to have all the neurobiological facts that she's requesting. I just read a little bit of science. 

Margaret: So I'm going to do the like thing they do in political debates where it's like there's someone, or not even political debates, but when they do the thing on like, I don't remember what website it is, but they do like a lie detector.

And there's just a guy in the corner going like, I'm going to do this when you're talking. 

Preston: Yeah. I don't know. Please. Yeah, please interrupt. So that's. I kind of wanted to, um, start with how we think about wakefulness and our circadian rhythms as they pertain to light, specifically, or just as it pertains to like our environment as that regulates it.

So, one thing that we talked about earlier was that there is something [00:26:00] chronologically consistent about seasonal affective disorder. So, when you think about Humean causality or the idea An anticitant event and a following event? Yeah, so like David Hume, that philosopher, he talks a lot about causality and one of the, one of the ways of a 

Margaret: Is it antecedent or is it antecedent?

Preston: Have I been saying it? 

Margaret: I've been saying this wrong my whole life. Like ligand or 

Preston: ligand, you can say both, I think. 

Margaret: Epitome, and I was one of those people who said epitome for a long time. Continue. Oh, 

Preston: epitome is wrong, but the British will be like Well, I know that. 

Margaret: We all learn. Aluminium. 

Preston: Canceled. Yeah, so Anyway.

So, if something, the strength of causality is improved if we see two things are present together and then they're both absent at the same time. Gotcha. So, that strengthens our correlation between them, which is what we see with seasonal affective disorder. So, there is a certain period of time During a season where when that season comes on, the depressive symptoms return.

When the season goes away, the [00:27:00] depressive symptoms reliably go away. So there's a lot of these, the research around seasonal affective disorders, both distinguishing it from what we'll call non seasonal depression for this episode and also like how multiple things contribute to this like systemic So the idea is like a trigger, something going on.

So I'm going to use this word, it's called a Zeitgeber, have you ever heard of that? 

Margaret: I have not. New word alert. 

Preston: I took, yeah, I took a little bit of German and it's a Zeitgeber, it means time giver and all that is, is it's any sort of external or environmental stimulus that leads to um, time related reactions in your body or chronological reactions.

Like 

Margaret: coffee? One of those? Yeah. 

Preston: Caffeine sure could be a zeitgeber. Really classic ones are light, like we talked about, could be temperature, could be exercise, could be eating. So for example, they say like, don't eat right before you go to [00:28:00] bed because that's going to cause a cascade of different time dependent actions that could wake you up more rather than helping you fall asleep.

So light as this, as this. The Zeitgeber is the primary driver of wakefulness and circadian rhythms. That's pretty decently established. And it does it through a couple interesting mechanisms. So first we're going to start out with melatonin, which, which you're familiar with. I imagine everybody loves melatonin.

So how do we, how do we get melatonin to release naturally? 

Margaret: That's a good question. I knew this at one point, I feel, but I don't think I can say reliably what it is. How do we get it to release? Like, we stop looking at light? I don't know. 

Preston: We look at light. That's it. So, we have, I love, um, the way our proteins interact with physics.

So, you know, rhodopsin is I 

Margaret: did at one point Like 

Preston: the rods in our eyes, rhodopsin Oh, yeah, yeah, yeah. Yeah, so that, so that's a protein that it responds to [00:29:00] wavelength of light and what it does is it just uses a single double bond, do you remember like the cis and trans double bonds from chemistry? Mm hmm.

Mm hmm. So, it puts it in cis, which is high energy and when a little bit of light hits it, it pops into trans and when it does that, it tells you in the back of your head, hey, there's a color here. Mm hmm. So, you have rhodopsin is associated with like different levels of light and dark. Mm hmm. Mm hmm. Okay.

As the thing cycles and just the bonds just pop back and forth, it tells us, hey, I'm seeing light. Right next to rhodopsin is another protein called melanopsin. Uh oh. Which does a similar thing, so, but instead of saying, hey Preston, you're perceiving brightness, deep buried in these, um, retinal ganglion cells, it just releases melatonin.

So there's a specialized protein encasing which has almost like a little apparatus that responds to the wavelength of light. Causes and adjustments to G coupled protein receptor and [00:30:00] then it then releases melatonin directly towards the suprachiasmatic nucleus, which is a spot in our hypothalamus that regulates our circadian rhythms.

Margaret: And so when we see a certain kind of light, it releases that? Correct. Then how does that, is it like, A specific wavelength of light that make us like that would make me think that if we saw light, then that would make us sleepy. But is it like the specific? 

Preston: Sorry, I'm I may be mixing this up. I think it's It inhibits the release of it.

Yeah, I think it, so I think it does, I want to say it releases melatonin, or I think, let's just say that, I'm not going to say if it directly stimulates or, or inhibits the release of melatonin, but that this light 

Margaret: modulates it, 

Preston: this light, light is, light interacting with melanopsin, Causes a structural change that mediates the release of melatonin in the suprachiasmatic nucleus.

So that's, [00:31:00] that's all said, but I don't know if like bright light leads to this or dark light leads to that directly. We just know what the output is. So that's, that's what I would say is the best summary. And the reason that's relevant is because it helps us identify as the primary driver of circadian rhythm.

So they, so they took mice where they didn't, knockout genes. So they just removed this protein from those mice and they had no ability to regulate their circadian rhythms when melanopsin was taken out. So, so we had a good understanding that like both light and melatonin are very important for circadian rhythms and it's not necessarily run by a bunch of other neurotransmitters.

However, alertness and wakefulness, they have a lot of roles to play. So as we know, dopamine is a very stimulated neurotransmitter, which has a huge role in wakefulness. It turns out, our release of dopamine is kind of independent of melanopsin. So melanopsin kind of, you know. Yeah. It sits on this highway with melatonin, the suprachiasmatic nucleus.

[00:32:00] Dopamine is needed more by just broads and cones responding to light. And dopamine is going to activate our reticular activating system and help us engage a lot more with feeling alert and awake during the day. So when light hits our brain, it's, it's affecting multiple different proteins and it's kind of going down different pathways to make us feel better.

Right. Feels that we've woken up. Yeah. I think 

Margaret: a complicated but consistent concept in neuroscience, including in this type of thing with like wakefulness or modulation of alertness, is that there are multiple places on the sort of circuit of function that we're talking about in terms of like a cognitive or whatever wake, like a brain body based function.

And so there are many places where there can be inputs or kind of screw ups. So like, you're talking about like this, if we don't have light through this kind of like the modulation of melatonin and that on wakefulness versus like dopaminergic modulation. I also think of like [00:33:00] clinically, like, why does delirium cause people to kind of sundown or to have waxing and waning alertness, which sometimes people will confuse as, Memory or tiredness, whatever.

So I don't say all that to just confuse it, but just to say that there's a lot of interacting parts in a circuit of if someone's awake, attending or asleep, a low alertness, um, that we're still figuring out. Would you agree with that? 

Preston: On a sec, you kind of lost me. I'm not sure if you're getting that.

Margaret: There's multiple parts of the, like, kind of like circuit of things that make someone appear awake. There are many 

Preston: factors that contribute to our concept of like wakefulness, whereas it's easy for us to view it as just like an on and off switch. It's a bunch of bells and whistles and dials. And that's, that's exactly what we see here too.

So another thing, our third character [00:34:00] today is going to be Sarah Tonin. And I don't thoroughly understand how Ms. Tonin relates to wakefulness, but we do know Um, like that, that it's released in sleep and modulated at the different layers of, of sleep, especially REM sleep. And so what we find in biopsies between patients that have like seasonal affective depression and non seasonal depression is that there are differences in our serotonin receptors.

So there is actually less serotonin reuptake transporters in the seasonal affective. Form of depression rather than non-seasonal depression. 

Margaret: Wait, so was, does that mean there was, if there's less re-uptake, that means in non-seasonal depression, there was more left in like the synapse, 

Preston: so. I think the only good conclusion we can make from less is that there's less because it could be there's [00:35:00] less serotonin in the synapse, which leads to less regulation of these reuptake transporters.

So it's, it's hard to like make it make a 

Margaret: concrete conclusion, but we just, 

Preston: so that's what I mean. It's unsatisfying. 

Margaret: Yeah, 

Preston: we know that there's a different level of this protein, but we don't actually know what's happening in the synapse. But we do know that like, there are characteristics of this disorder that are distinct from non seasonal depression.

The other thing that's been more robust is there's been a couple studies looking at levels of melatonin in patients who have seasonal depression versus non seasonal depression. And it's a bit controversial, but pretty consistently, they've been able to demonstrate that there's higher levels of melatonin.

During the day in patients with seasonal depression, which that does kind of make sense intuitively. Feeling more tired during the day and not being able to eliminate your melatonin, feeling more awake. Correct. Huh. So the reason why I bring up serotonin, dopamine, and light is because those all kind of track on the three [00:36:00] ways that we try to treat seasonal depression.

And so before we kind of go into these treatments, I want to talk about our hypothesis of like what even causes this as we get from Kind of the mechanism of light causing us to be awake, but why does it affect some people more consistently than others? So, there is this latitude hypothesis for a while that really just observed that there is, there's a linear correlation between your northern latitude and the rate of the incidence of seasonal affective disorder.

So, the paper I was looking at started in, let's see, they started in Nashua, they went down to New York and then Montgomery And then, uh, Sarasota, I don't know where Sarasota is, but it's at 27 degrees north. Very far. Oh, it's in Florida? Yeah. Yeah. In Nashua, it was 26 percent in the, um, the patient population that they studied, and it dropped down to 13%.[00:37:00] 

In Sarasota. Yeah. So, so there was almost a depending, correlating, and then it goes linearly. So, correlating with your latitude as you go down it tracks consistently with the rates of seasonal affective disorder. So, so there's this thought that, hey, maybe people who are born in different latitudes just don't have like the genetic predisposition.

position to handle this and then their rates will decrease or their rates will then increase. But what we found is that there's a couple holes in this theory. One is that people aren't restricted to their latitude. So some people move into higher latitudes and then experience seasonal affective disorder.

Some people maybe move out of latitudes because they have seasonal affective disorder. So may kind of change the rates that we see in different areas. And also when we, when you take People from like Iceland, for example, and um, track them and they move into Canada, which is still a high latitude, but yeah, lower than Iceland.

They, they have less rates of seasonal affective disorder than people within Canada. So [00:38:00] there's, there's some genetic components here, but there's a lot of more questions than answers about the relationship just between latitude and the prevalence of seasonal affective disorder. 

Margaret: So there may be something, you know, there may be something genetic and this also kind of gets into some of the like, how do we, you know, this is a little bit about the vitamin D stuff, but not completely, but that like, you know, I don't I need sunscreen 24 7 all the time for me to not burn, and how we modulate the sun, uh, is depend like, is something to do with our vitamin D kind of levels and then synthesis and da da da, we're not gonna go into it because frankly the research on vitamin D is super duper confusing to the point that The Society of Endocrinology released a clinical guidelines update and it was like literally in the paper there's like a narrative editorial on it that was like, hey, guys, we could only [00:39:00] like really give recommendations on six questions.

We know you want answers to more, but we aren't sure yet functionally. And, um, But I think with seasonal affective disorder, one of the things we haven't talked about or we've alluded to a little bit before we even talk about treatments is like, one of the things you're saying it sounds like is in this moving, like, a population from Iceland into Canada, that they were still doing better despite, like, compared to the population there.

And that gets into actually some of the pop culture stuff with different concept like, I'm going to mispronounce this, but like the concept of like hygge, which is like H Y G G E, um, or some of the things I think Catherine Mansfield has written really well about wintering. Oh, sorry, Catherine May.

Catherine Mansfield's a different author. Catherine May wrote the book Wintering, which, Is just the question of like, how do we make sense of the season of winter and snow and how do you prepare [00:40:00] for it and something that that book talks a lot about and then other books, um, from different regions, especially the like, Nordic, Scandinavian regions is like that they make sense of winter in a very different and more active way than a lot of places.

Um, and so I feel like there's a lot of ways in which it interacts with like our meaning and culture of how do we interact with it. 

Preston: Yeah. Yeah. So it's, it's all three. Um, like we come back to the biopsychosocial model, someone in Iceland may have a different psychological relationship with winter and they may be able to be more active when it's dark 23 hours a day or 20 hours a day.

And then also they may have certain genes that allow them to maintain lower levels of melatonin throughout the day and feel more awake when they're not having that same level of stimulation. Yeah. Yeah. 

Margaret: Yeah. And they may be someone also like outside of where you are in the world. If you are someone who has a predisposition towards quote unquote regular non seasonal depression, [00:41:00] Um, I think that does put you at higher risk for not necessarily seasonal depression, but like, if you're someone who struggles with depression all year long, maybe the ability to tolerate these changes that induce somewhat of a lower mood or more fatigue, or I think about people who have like, chronic fatigue due to a variety of like, chronic or autoimmune illnesses, like, the predisposition towards depression in general, but also towards these things that make it hard to do other parts of like, Behavioral or lifestyle things that help with mental health more difficult, um, is also a part of how I talk to my patients about seasonal affective disorder.

It's something that they're worried about or have experienced before in addition to the medication and therapy parts. 

Preston: Yeah, it's the ability to have like a social support system or community despite changes in the environment are huge. So I'm still thinking about that person in Iceland who maybe their entire community is still active because they're just so used to having these like very dark days where somewhere in, I don't [00:42:00] know, Vancouver, I shouldn't say Vancouver because Tessa's, Tessa's from Vancouver.

She's in British Columbia, right? Maybe they don't have the same like level of community despite because there's a lot of people who have moved from other other areas. There's not the kind of like robust insular culture like you have in Iceland where there's like 200, 000 people in the entire country.

So, so everything is like very tight knit and very like strong with their sense of culture despite these changes. So now that we kind of can look at these three pathways initially, so we have light can kind of stimulate our rods and cones to help with dopamine release, help with release of norepinephrine from the locus aurelius as well.

We have light mediating our circadian rhythms via melatonin, which is really controlling When we start to get ready to go to bed and when we start to feel like we're awake again, and then we know somewhere involved in here serotonin has a role that it's playing, we don't want to make too many assumptions about whether it's too much serotonin, too little serotonin, but some amount of serotonin [00:43:00] dysregulation is happening, um, likely post synaptically.

So when we treat it, the first line treatments are classically SSRIs and light, and So, um, if you look at kind of the range of SSRIs, the ones that are most effective are tricyclics actually, and that's consistent with other types of depression. So amitriptyline is extremely effective, um, compared to 

Margaret: I feel like I've I've seen more of like first line being SSRI rather than 

Preston: Well, so first line still is SSRI.

But if, if we go just off of effectiveness, a tricyclic will be the most effective, but tricyclics also have the greatest risk of adverse effects compared to SSRIs. So if someone can achieve that benefit with Lexapro, and the reason why I bring up something like amitriptyline is because in addition to serotonin, it also has norepinephrine and dopamine.

Right, [00:44:00] which makes sense. So it kind of It goes across all three, whereas first line for us would be something like Lexapro, but 

Margaret: I think it was like Prozac and Lexapro were the ones that were the SSRIs most studied, which again, I think probably lines up more importantly than the specific SSRI class is SSRIs are effective.

There's a whole, there's a whole game to like, what is like indicated or FDA approved, recommended in terms of these medications based on like funding to get studies to get it to be like, this is more effective or whatever for this specific indication. So, yeah, I think SSRI is our first line, but then you're saying there may be added benefit in this kind of case with a TCA because of other modulation it's doing, which, which makes sense.

Preston: And I think it's, it's hard to take into account because you're, you're looking at like a quick on quick off type of treatment. [00:45:00] And so the other class of medicines that studied, um, the second generation antidepressants, so things like Welbutrin. Yep. Um, have also shown some efficacy and Welbutrin specifically, yeah, um, performed well in preventing, um, the onset of seasonal affective disorder.

So what the patients would do is they would start taking Welbutrin in about October before you expect it, uh, the onset of the symptoms. And then we would significantly see prevention of the seasonal affective disorder as we go through. Right. So 

Margaret: I'm quite pro the Wellbutrin in this case, just in terms of like what you classically think of as a seasonal depression symptoms and what Wellbutrin is really good at hitting versus an SSRI.

Preston: Yeah, I agree. And I think like, even just like, If I was a high school student, didn't know anything about science, I do know it's easier to stay on a bike than it is to get back on a bike once you've fallen off. So [00:46:00] if something's going to keep me awake and keep me stimulated so that I don't develop this, it's going to be so much better to keep the momentum rather than waiting until I develop these symptoms and treat it with an SSRI.

And then The other treatment we have is light, so we have phototherapy and it's measured, yeah, it's measured in lux, so my question to you is, do you know what a lux is? 

Margaret: No, but you 10, 000, right? 10 million lux, 

Preston: yeah, I think I have a light that's like 28, 000 lux, it's pretty bright, I wish I got one of the lights.

Margaret: This is Preston's Vogue. I can go outside to see the sun. Happy mental health secrets. 

Preston: Well, so I got the light actually when I was on medicine and I was going to the hospital at 530 and I'm coming home at 8. So I wasn't seeing the sun. So I would just try to blast myself with this 20, 000 Lux lamp while I was brushing my teeth.[00:47:00] 

You're supposed to do it for 30 minutes. Yeah. So I'm like, okay, I'm just, I'm just going to sit like plants on my mirror and just blast my face while I'm brushing my teeth. And for 30 minutes? 

Margaret: No. Do you know you have 30 minutes? 

Preston: So, so I would unplug it and then I would carry it with me. To breakfast and I would plug it in and I would sit and eat my sad oatmeal with this light blasting me.

And I did, I felt more awake when I went to work. Like I did notice a difference with it. Like I couldn't see, 

Margaret: but I felt, 

Preston: yeah, even, 

Margaret: yeah, it has to be more, it's like, what is it? I forget what the stat is, but how many times more powerful it is than like a regular lamp. They are, I will say, not vibey and not aesthetic, like it's like blue light, I'm more of a warm light person, so they're, they're interesting in terms of the aesthetics, but I'll, I'll give it, it's kind of like a grow light for 

Preston: humans.

She would like, she would go like airplane ears and be like, why is this light [00:48:00] on 

Margaret: Preston? 

Preston: So, we, we do find that these lights are effective though, and, and when compared to something like Lexapro, they actually perform similarly. for listening. Um, yeah, with regard to seasonal affective disorder, and then there's actually.

You 

Margaret: don't have to wear sunscreen while you have them, right? I don't know what your light is like. You're like, I'm actually in a tanning bed. We don't recommend tanning beds 

Preston: on this show. I turn around and my whole back of my neck is white compared to the front. You actually 

Margaret: show up in the next episode wearing the teeny tiny tanning.

Although that's part of why there's vitamin D controversy is like, the tanning 90s advocating for tanning beds as like treatment for part of seasonal effective and like low vitamin D. I think 

Preston: vitamin D might deserve its own episode. 

Margaret: I agree. 

Preston: Yeah, 

Margaret: tune in Patreon behind the paywall vitamin D. One for 

Preston: D2 and one for 

Margaret: D3.

Preston: So it's so it has less side effects it can be equally as effective, but it's hard to be honest. It was [00:49:00] kind of annoying to do this 30 minutes every day because it's so easy to just take a pill and then I put Pills in my backpack, like my meds in my backpack too. So if I forget them, I'm like, Oh, I'll just take one at work right now.

It's kind of hard to be like, Hey guys in the workroom, let me whip out my 20, 000 

Margaret: bucks. Hey guys, I'm actually filming a POV med student TikTok and then I have to do 60 minutes of my light therapy while I do push ups. Is that chill with 

Preston: you guys? If it bothers you, just close your eyes. Don't worry about it.

So there are some, the point is there's some feasibility challenges with these, with this light therapy. Um, and it does have some benefit for non seasonal depression as well, though it's a little bit less robust. Yeah. Weirdly enough. Is your ring light that you 

Margaret: use like secretly a happy light? So you're like, anytime I'm filming a TikTok, I'm actually in therapy right now.

Preston: I should, I should do that. Shark tank? 

Margaret: Did you hear that? Like, solving the mental health crisis of influencers. It's 

Preston: like, yeah, remember, remember you're [00:50:00] happy while you're staring into the light. The lifeless abyss of like a social media parasocial chasm. 

Margaret: Don't think too hard about it. 

Preston: So there's one more medication that I wanted to talk about and it's called agomelatine.

Margaret: Oh yeah, you were, you had said this. I don't know anything about it, so I'm gonna let you teach this. 

Preston: Yeah, I'm happy to Because why? Why do I 

Margaret: not know anything 

Preston: about it? You don't know anything about it because it's a European medication. So it was synthesized in the early 2000s and it's an M1, M2 agonist, so it hits melatonin receptors and it also has, I believe, HT2C activity, so it affects serotonin receptors as well.

It's not very selective for the SIRT receptor, so not a lot of serotonin reuptake, but it hits these downstream serotonin receptors. The reason why it actually Um, faceplanted in the US is when we did trials in 2011, um, some people reported, um, elevated LFTs with it. Oh, 

Margaret: yeah, we [00:51:00] hate that. 

Preston: The risk of, like, liver dysfunction was too much and we pulled the plug on it.

Um, further studies show that, like, Europe actually hasn't run into too many problems with, um, elevated transaminases or LFTs in patients and, uh, the last study I read on Um, there is no significance between placebo and the alga malatine group. Nonetheless, I'm glazing alga malatine right now, but I think it can be worthwhile bringing back into the US, and I'll tell you why.

Margaret: Docs. That's mad. So. 

Preston: It's, the idea is it's basically an antidepressant and a circadian rhythm stabilizer at the same time because it has the serotonergic activity and also hits melatonin receptors. So in patients, you can take it at the same time every day and it stabilizes. Imagine if Romelteon had SSRI effects.

I think that's a good way to think about ecomelatine. Yeah, yeah, yeah, yeah. So, we find that even when we put it head to head against antidepressants, it's [00:52:00] up there with like similar effectiveness to even amitriptyline and fluoxetine, but it's much better tolerated. In general, so a lot of people do well with agamalotene consistently for these like small periods of time where they can both stabilize their circadian rhythms and also have some like more mild, um, like mood uplifting benefits.

So maybe 

Margaret: the people from Iceland in that study, they brought their European medication. To Canada. 

Preston: Yeah. And we're just like watching them totally fly compared to us on the Ag and Mel team. We're like, 

Margaret: must be nice. Okay. So overview of that is maybe helpful. A couple of studies here in 2011 did not like had some concerns in terms of side effects.

That has not been as much of a concern. In use in Europe, the mystery goes on. 

Preston: The ultimate point is that um, Agamelotine [00:53:00] is really effective for specifically Seasonal Affective Disorder. So, the thought is if we stabilize both melatonin and serotonin receptors, we can get that extra benefit for what appears to be a, a separate but similar syndrome to non seasonal depression.

So, that's our takeaway from it. And then if we look at new medications in the future, are we going to augment with Melatonin agonists or melatonergic drugs. Yeah, 

Margaret: well it makes me wonder when you're saying like imagine this and I think there's side effects to full on like different serotonergic modulation of an SSRI versus this medication you're describing, but like is there a place for like a combination of like remeltion and An SSRI to help with 

Preston: both?

Yeah, that's a great question and I don't know the answer. So I haven't actually looked into too much of augmenting with either melatonin or remeltion while also giving an SSRI, but I think in theory it's, it's a great idea or place to start looking. [00:54:00] Yeah. 

Margaret: Yeah. Yeah. I mean, I think the melatonin, we won't get into melatonin today of like, at like supplements with melatonin.

We won't get into that. Let's tune in for a sleep episode someday. I think the thing we haven't talked about, which is near and dear to my heart, is therapy and behavioral activation for seasonal affective disorder, which is the other tried and true of the three, um, in terms of efficacy. So, there's a bunch of different ways you could approach this in terms of therapeutically, um, I don't know actually if there is, I know you had been thinking about like CBTI or cognitive behavioral therapy dash for insomnia, which is a specific protocol of someone struggling with insomnia, um, which can happen in seasonal affective disorder just with like the sleep wake dysregulation in terms of insomnia happening.

Um, I really think a lot about behavioral activation and then with some of the things we were talking about that are sort of the psychosocial determinants [00:55:00] of what someone's mental health experience would be. And so what that looks like is me asking about a lot of lifestyle things and trying to actively plan with my patients, both optimizing their meds, talking about the light therapy, but also in September being like, Okay, what are the things that if I met you in the winter last year or years before, like, how, like, what would, what would be different from what, what's right now, like, what do you notice in terms of your social behaviors, um, what do you notice in terms of your change in exercise or movement, in terms of eating and appetite, sleep, um, and then, like, engagement with hobbies and work?

I think especially, like, during post whatever COVID with, like, work from home, it's particularly, Difficult for a lot of folks because there's, there's not a lot of impetus to leave your house and go out into the cold when it's dark when you get done with work at 4 p. m. 

Preston: I think people that spontaneously [00:56:00] socialize when the weather's good are very vulnerable to spontaneously not socializing when the weather's bad.

And people with Social obligations that are built into their schedule may do better. So and I'm just speaking from personal experience. I joined a soccer league and I have to go to my soccer game every Wednesday night. So even as it gets dark and gets cold or all those things, I'm like, oh, darn it. I still have to go to my soccer game where I have to interact with other human beings and exercise.

So those people have built in like Community prescribed to them. I think that's that's a great. So joining a league or something like that is a great way to behaviorally activate yourself and also create accountability, 

Margaret: right? I think similar. I think, yeah, well, we we recently did the exercise episode and have talked about the many mental health benefits of that, which probably also apply in these cases to you.

So having something that gets you socializing, exercising, and doing exercise being [00:57:00] something you enjoy or find satisfying in some way like you're describing are three potent ingredients. I think this can also be a time where like engaging with a hobby or for people who have like religious or spiritual communities or volunteering communities they belong to.

Like making a commitment to that or having a regular, a recurring routine with that where like in the case of religious or volunteer spiritual communities, again, there's this like really active involvement both with people but also engagement with the values you have about belonging and community that there's some positive social peer pressure similar with your soccer league that gets you out of your house and doesn't rely on the sense of like feeling it because I know for me when it's like January and dark out, like I'm, I'm going to my, like, whatever volunteer extra, like, writing class thing I take.

I'm not going to that because I'm like, I really feel like leaving my apartment and being cold in Boston. I'm like, I paid for this and my friend [00:58:00] said that I was going to be there and I'm going to disappoint him. 

Preston: I don't. Yeah. And like, the fear of disappointing others may be what kicks you out the door and then you feel better when you do the thing.

Right. I think one thing you have to accept early on about going off of whether or not you feel like you want to do something is that. You just need to anticipate that the feelings never going to come and just, just start now. Like I had to learn that with homework and exercise and 

Margaret: writing clubs, 

Preston: podcasting.

Margaret: I think also with this, like, is this marriage. And we talk about, I think about this a lot in psychiatry, like of encouragement or this part of like, I'm going to have feelings that are going to get in the way of the kind of life I want to lead. And sometimes that'll mean pushing to do it anyway. And self compassion, I think something that is really.

Hard for people in Western culture, and I think, like, a lot of people maybe who listen to us who are in health care, or who just can, like, value being a productive person. Or type A person in society [00:59:00] is, again, this is anecdotal, but kind of a question I pose to my patients of, well, what if it was okay if this season was a little slower?

Like, what if this is, there's like a purpose to this sort of season of needing a little extra sleep? Or like, is all of this pathologic? Like, is all of this seasonal depression a mental illness that we need to like combat? And in a lot of cases it is, and we need to, with like I do not want anyone to hear that as like, you're not suffering, but I do think some of it is this like hyper productivity culture that makes it so that like something is wrong and an alarm bell should signal if you're like, I actually am a little more introverted during the cold months, but I don't mind that.

Preston: Well, I think where it's really hard in people, especially in Western cultures, they punish themselves for emotions or desires. They don't have the desire to go out, and then they feel guilt about that. And so I a lot of times in therapy will unpack people about unpack that with [01:00:00] people and work through just not even punishing yourself for emotions and kind of the analogy I use is like imagine if you were in pain and then you punish yourself and you're like I shouldn't be in pain so now I feel guilty that I'm in pain like kind of to have that same relationship with your desires and your hesitation your fears like those are all things that are telling you something and it's so easy to just get mad at yourself for that but Having self compassion for feeling tired.

Like, of course, I would feel tired. I'm seeing the sun less. It's cold outside. So, while on one hand, it's understandable that I would have these feelings, on the other hand, I want to go do these things that are going to make me feel better and activate me and I shouldn't feel guilty about being tired.

Margaret: Right. And there's something, I think, There are physiologic things about behavioral activation exercise community that make it easier, like, make our moods change over time so that we do feel more like it, um, and that's a really important part of, like, the [01:01:00] therapy approach is also, as we are learning more and more neurobiological, like, that there's neurobiological changes to kind of how, like, 

Preston: habitual changes I don't have anything smart to say about it, but like from a neurobiological perspective, the momentum is so powerful.

Margaret: For 

Preston: me, it's, it's, it's just incredible. Even if I start a certain type of workout, like if I run, I want to keep running. Like I continuously want to keep doing my running. And recently I've been doing Pilates and now I signed up for a Pilates class after this. I just want to keep hitting Pilates. Yeah, it's so challenging.

We'll agree. Unbelievably challenging. What are we doing? 

Margaret: Do you know why it is more challenging for you? Besides that it's new to you and why like it might be easier for women is because we actually have more type one fibers, which are endurance and Pilates is primarily. There's like the center of balance stuff too, but Pilates is primarily like greater than 60 seconds repetition over minutes, and we have more type 1 fibers, and so we [01:02:00] can like recycle that more, whereas men on a whole have more type 2 or fast switch fibers, um, which, fun fact, we can cut that out, it's probably not that fun to anyone but me, but I think it's interesting, um, I feel like though that what you're saying, maybe, maybe you're not saying this, but like, 

Preston: mhm.

Margaret: I think a question that can be really fun, especially if you ask it before the season, before people are feeling down, is getting really creative with ourselves, with our friends, and with our patients around like, what if, what are things that you can only do in winter? Um, and this is what I write about a lot on TikTok is like, what if, I like to think of it as, I, the series I write on this on TikTok is called Winter Mysticism, which is the idea of like, the positive invitation of solitude and community and like creativity, what?

Preston: Why? Why are you laughing? I'm just thinking about how I romanticize my solitude. 

Margaret: Yeah. 

Preston: Only in winter can I, can I be the lonely rider atop a hill [01:03:00] in a cabin? 

Margaret: Well, no, I mean, yeah, so it's different for different folks. Again, this doesn't cure seasonal depression, but I think the idea for me, like one of the ones I've been thinking about is when it's the summer, especially here as Preston knows in New England where he's like, we get it, you live by an ocean.

Um, but In the summer, I want to be outside. I want to be like doing the things I can't do all year, but in the winter, like there is time to like really learn how to cook some new recipes that I've wanted to. And it's okay to take that time because I don't really want to leave my house. It's okay to spend a long time reading books and drinking coffee.

Go strike a note of 

Preston: mode, yeah. 

Margaret: Yeah, I'd be living that life. 

Preston: For me, it's snowboarding. 

Margaret: Yeah, yeah. 

Preston: reframe winter. I'm like, ah, winter's coming. I'm like, yeah. But I can snowboard. 

Margaret: Mm hmm. Mm hmm. 

Preston: There's like something else I can do. And actually, I have a snowboarding trip planned. So it's community. Yeah, I'm regrouping with my friends and exercise and [01:04:00] something you only do in winter.

So that's my way of combating seasonal affective disorder. 

Margaret: I, I will say one thing that I think is a hoot and I think it is evidence based, but like one of the things in the papers from the primary people who started like kind of the research and coined seasonal affective disorder is like a recommendation in the summer to book a trip in the winter somewhere warm where you'll see the sun, which I think is neurobiologically sound, but I love that that's like, like, like that's a clinical recommendation and it's true, but obviously it's not in reach for everyone.

I have to 

Preston: go to Mexico. You can prescribe a. A gym membership to someone? 

Margaret: Yes. 

Preston: Yeah. Can you imagine if you could prescribe like a vacation, like an all inclusive vacation? 

Margaret: Disney Cruise. It's like, yeah, my insurance is going to cover this 

Preston: trip to Costa Rica. That's really funny. 

Margaret: Um, yeah, so Preston and I are going to be doing a retreat, just kidding.

Yeah, so, 

Preston: um, I'll be, I'll be right back. I'm going to be lobbying Congress to let me prescribe [01:05:00] vacations to people. 

Margaret: Prescribing vacations. That would 

Preston: be so therapeutic. 

Margaret: Just be the, what is the thing, the like, the captain of like the Lido deck on cruises? 

Preston: I've never been on a cruise. I have no idea what you're talking about.

Margaret: Okay, well, we'll talk more about cruises in the 

Preston: next episode. Okay, so, so our cruise episode is coming up next. Uh, just kidding. People have been wondering, people have been asking 

Margaret: about when, when is the cruise episode going to come out? 

Preston: I think that's all I had. From my end, any, any closing remarks, Margaret?

Margaret: I don't think so. I think we've covered a lot of different parts of wintering and we, in the show notes, we'll put some of our references as well. I will include some links to the books I like about romanticizing winter mountain clinically. 

Preston: Yeah, that sounds great. So to the listeners, our, our third member in the room, thank you so much for listening.

If you liked the show, if you didn't like the show, please submit your questions. We want to hear them. We just want you to be a part of the conversation. Really, um, I see this as like three people in the room, me, Margaret and the audience. And unfortunately, you guys don't get to talk during the [01:06:00] show. So I want you to talk after the show, if that makes sense.

Yeah. And if you want to do that, you can come chat with us and the rest of the human content family on IG on TikTok at human content pods. Or you can contact the team directly at howtobepatientpod. com. Thank you to all the listeners that left kind feedback and awesome feedback. I loved it, and I read all of it, and I didn't respond.

And I know I didn't respond, but I'm busy, and I feel bad about it, but also I still really liked it. You were celebrating Honda days, you 

Margaret: guys, okay? Wake up, Honda, if you want a sponsor. Wake up. 

Preston: The Honda glazing has to stop. Wanna it. 

Margaret: It will never stop. My family's 

Preston: full of haunted 

Margaret: blazers. 

Preston: full episodes are also available.

full episodes where you can be interrupted by Margaret are also available on my YouTube channel at it's prerow. Thanks again for listening. Where your host, Preston, Roche and 

Margaret: Margaret, see her name Margaret Duncan. 

Preston: Our executive producers are me, Preston Roche, Margaret Duncan, will Flannery, Kristen Flannery, [01:07:00] Aaron Corny, Rob Goldman and Shanti Brook.

Our editor and engineer is Tracy Barnett. Our music is by Ooma Ben v. Check out our show notes and see references for the resources we discussed during the episode. To learn more about our program disclaimer and ethics policy submission verification licensing terms on our HIPAA release terms, go to our website howtobepatientpod.

com or reach out to us at howtobepatientathuman content. com with any questions or concerns. How to be patient as a human content production. 

Margaret: Do an eagle sound.