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Why Am I So Irritable In The Winter?

Q: Is there anything that can be done for seasonal depression? The long months of overcast skies and reduced sunlight never had any noticeable effect on me in my youth, but as I approach middle age, I find I’m irritable, fractious, melancholy and generally about as pleasant as a plowed-up snake from about mid November until at least mid May. Last year was the worst ever. Since I plan to live through at least another 45 winters or so, it would sure be nice to know if there’s anything I can do about this. – Sean

Dear Sean,

seasonal affective disorder and agitated depressionAs someone who once plowed up a snake, I can appreciate your metaphor.

I exaggerate. In truth, I was using a spade, not a plow.

And it wasn’t really a snake. It was a small earthworm. But it was frightening.

Please know that I’m not making light of your symptoms, but rather drawing attention to them in my own tactless and ham-fisted way. You sound irritable more than you sound depressed, and the true sources of irritability are commonly overlooked or misidentified – especially in men, for whom irritability frequently masks a mood problem.

Seasonal depression conjures images of sadness, hopelessness, despair, loss of energy, and other stereotypical depressive symptoms. While you mentioned sad feelings, the thrust of your complaint is that you are crabby during the dark months, not classically sad and depressed.

Might that be a flavor of depression? Let’s discuss proper diagnosis, and then we’ll get to the possible interventions.

Mixed Symptoms

You were kind enough to send me more information about the symptoms you experience during the winter months. Some of your symptoms match the typical picture of seasonal depression. For example:

  • You live in a higher latitude, where seasonal mood problems are more common than in those closer to the equator.
  • You go to bed earlier and sleep more in the winter.
  • You feel sad.
  • You gain weight (though you indicated that this is due to inactivity more than diet change).

So far, these are symptoms associated with what’s been termed Seasonal Affective Disorder (SAD), with the exception of your mode of weight gain. The condition is usually characterized by classic signs of depression, along with some unique features like carbohydrate cravings.

However, your picture is a little different. You did not endorse other symptoms associated with seasonal depression, such as hopelessness, difficulty concentrating, feelings of worthlessness, overeating, diminished interest in pleasurable activities, or loss of energy.

In fact, you told me, “it’s my attitude and not my energy that suffers.” You indicated that you lack motivation, not vitality, and that your inactivity during the winter months is due mainly to the fact that you cannot be outdoors where you tend to get exercise. “I’m not a guy who can go to the gym and get on a treadmill like a gerbil,” you wrote. You also informed me that you find yourself “going stir crazy with severe cabin fever mixed with the blues.” I take that to mean that you feel agitated.

So. During winter, you are fractious, stir crazy, sad, and stricken with inertia despite ample energy. So far, these are not the classical depressive symptoms as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the holy and ordained catalogue of mental illnesses. In fact, they don’t really match any diagnosis that I can find in the DSM.

Yet, in the first few words of your question, you surmised that you are struggling with seasonal depression. Perhaps you have a more nuanced understanding of mood disorders than the DSM.

While the DSM grows in size and weight with each iteration, the list of mood disorders is rather unrefined. The DSM contains fairly blunt descriptions of either 1) depressive or 2) bipolar disorders, to which one can add various specifiers (those are descriptions that denote a subcategory of the disorder). That’s it.

Any depressive disorder that doesn’t fit neatly into one of two broad diagnoses is lumped into the category Depressive Disorder NOS (not otherwise specified). Your symptoms might be tossed into the even less descriptive Mood Disorder NOS. There is a specifier called “With Seasonal Pattern” that can be appended to these diagnoses, but even with that you don’t fit neatly into a DSM box.

Normally, I don’t get too hung up on diagnosis. Heck, I mostly use the DSM to prop up the short leg of the couch. That’s because pinpoint diagnoses are marginally useful in my type of clinical work. A person might be diagnosed as alcoholic, but that doesn’t tell me why the person drinks, how alcohol functions in his life, or what to do about it. I’m usually more interested in function than category.

But where mood disorders are concerned, accurate diagnosis matters because they sometimes involve biological interventions like medication or phototherapy (we’ll discuss those shortly). The wrong intervention can make things much worse.

For example, a person with a history of manic symptoms can be thrown into a very unpleasant episode of mania if they are mistakenly prescribed antidepressants or even phototherapy. And applying antidepressants like SSRIs in a situation that is better managed behaviorally can have serious, long-term consequences.

Of course, I am not the first to point out the limited scope of DSM mood diagnoses and the importance of rediscovering the old wisdom that mood disorders cover a wide spectrum. In an editorial to the American Psychiatric Association, Christohper Shenk (2009) argued for a more nuanced understanding of mixed states, like yours perhaps, to help physicians avoid treatment errors.

Since the 1800s, people have found many labels for the various flavors of Agitated Depression – a diagnosis for which you might barely qualify for several months out of the year. That diagnosis usually includes some of the classic symptoms of depression along with inner agitation, racing thoughts, irritability, and so forth. In keeping with my tradition of advancing arcane trivia, here’s a sampling of the names that have described various mixed mood states (Koukopoulos et al., 2007):

  • melancholia phrontis
  • melancholia moria
  • melancholia saltans
  • melancholia errabunda
  • melancholia silvestris
  • melancholia furens
  • melancholia activa
  • melancholia excitata
  • melancholia delirans
  • melancholia persecutionis
  • melancholia convulsiva
  • melancholia maniaca
  • melancholia malevolens
  • melancholia homicidialis
  • melancholia metamorphosis
  • melancholia uterina
  • lycanthropia
  • melancholia enthusiastica
  • mania melancholica
  • melancholie maniaque
  • melancholia agitans

Clearly, this is not a new problem. Koukopoulos et al. argued that Agitated Depression is an important diagnosis that should be included in the DSM. Benazzi & Akiskal (2005) argued for the inclusion of a more specific diagnosis, Irritable-Hostile Depression, that more accurately describes a clear constellation of symptoms like those you describe, and has specific treatment implications.

Time for me to bring this to a point. I’m not picking on the DSM. No tool is perfect. But in your case, where a proper understanding of the problem is critical, there is no clear-cut diagnosis on which to base treatment.

OK. You’re Special. Now What?

I recommend that you meet with a licensed psychologist – not a psychiatrist – who possesses a clear understanding of mood disorders. He or she will want to gather your mood history and other diagnostic factors. (For example, you mentioned that you have two small children who might be affecting your marital bliss and your peaceful home. This is no small detail.) Also, get a physical. There are a number of medical problems that can involve mood changes.

But do not, I beg of you, begin a course of antidepressant medication without serious consideration. I’m not suggesting that medication is necessarily the wrong answer. Some pills like Wellbutrin have been successful in treating SAD. But there are serious tradeoffs to consider. Antidepressants are not the benign cure-all that their promiscuous reputation and liberal use would suggest.

Since you function well in the winter, meaning that you did not describe debilitating symptoms like becoming housebound or suicidal, you might want to begin by exploring least-restrictive, behavioral interventions like these:

Phototherapy. This involves exposure to a certain variety of bright light early in the morning. It emulates what one might experience outdoors when the sun rises. Light therapy appears to be effective with just over half of those who use this intervention (Rastad et al. 2008), and the effectiveness increases as the intensity of the mood problem decreases (Priviter et al. 20010). As already mentioned, proper diagnosis is important before applying this type of treatment.

Exercise. While it’s not typically listed as a primary intervention for SAD, I’m putting it high on the list anyway. As I’ve said many times before, exercise is a magic brain pill. It is every bit as effective for depression as antidepressants, but without the side effects or long-term tradeoffs. Exercise is the benign cure-all that antidepressants wish they could be.

You indicated that physical activity is important to you, and you mentioned that you might begin snowshoeing this winter. A fabulous idea. Even better if you do it each morning. If it accomplishes nothing else, it may prevent that winter weight gain. Exercise early in the day also helps to manage sleep cycles at night.

Sleep Management. Sleeping too much can have a depressing effect. It can leave a person fatigued, foggy-brained, and irritable, and it can put circadian rhythms out of whack. You might try keeping a sleep schedule similar to that of summer. An effective way to do that is to…

Manage Your Zeitgebers. Zeitgeber means “time giver” or “synchronizer.” All animals use synchronizers to keep their bodies in proper rhythm with the natural environment. For us, light exposure is the most prominent synchronizer. Others include exercise, social activity, eating and drinking patterns, and even temperature. (A decrease in temperature is one of the environmental cues that tells a body it’s time to bed down.) You can structure your environment and activities to capitalize on your body’s natural tendency to track with the environment even when certain zeitgebers go missing for the season.

Nutrition. A psychologist should be able to talk to you about diet and supplements that help with mood. There is some evidence that a proper balance of carbohydrates can improve SAD (Mischoulon et al., 2009). Vitamin D also seems to play a role in various forms of depression, including SAD (Penckofer et al., 2010).

Other treatment options include cognitive-behavioral therapy specifically for SAD and, of course, antidepressant medication.

While I don’t have enough to go on, Sean, my Spidey-sense tells me that your condition may be particularly responsive to behavioral interventions like exercise, nutrition, light exposure, and sleep management. My suggestion: get thee to a psychologist for a proper assessment before the winter. I hope you’ll let me know how it turns out.

-IS

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Benazzi, F. & Akiskal, H. (2005). Irritable-hostile depression: further validation as a bipolar depressive mixed state. Journal of Affective Disorders, 84, 197-207.

Koukopoulos A., Sani G., Koukopoulos A.E., Manfredi G., Pacchiarotti I., & Girardi P. (2007). Melancholia agitata and mixed depression. Acta Psychiatrica Scandinavica, 115, 50-57.

Mischoulon, D., Pedrelli, P., Wurtman, J.,Vangel, M., & Wurtman, R. (2009). Report of two double-blind randomized placebo-controlled pilot studies of a carbohydrate-rich nutrient mixture for treatment of seasonal affective disorder (SAD). CNS Neuorscience and Therapeutics, 16(13-24).

Penckofer, S., Kouba, J., and Byrn, M. (2010). Vitamin D and depression: where is all the sunshine? Issues in Mental Health Nursing, 31, 385–393.

Privitera, M.R., Moynihan, J., Tan, W., and Khan, A. (2010). Light therapy for seasonal affective disorder in a clinical office setting. Journal of Psychiatric Practice, 16(6), 387-393.

Rastad, C., Ulfberg, J., & Lindberg, P. (2008). Light room therapy effective in mild forms of seasonal affective disorder – a randomized controlled study. Journal of Affective Disorders, 108, 291-296.

Schenk, C.D. (2009). Mixed Depression: The importance of rediscovering subtypes of mixed mood states. American Journal of Psychiatry, 166, 127-130.