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Shedding Light on Seasonal Depression: Practical Strategies for Pediatric Care · Pediatrics in Practice: A CME Podcast

• 0:01
  Mike (Host): Welcome to Pediatrics and Practice, a CME podcast.
• 0:05
  I'm Dr.
• 0:06
  Mike, and joining me is Sarah Gould, a clinical psychologist
• 0:10
  from Children's Mercy.
• 0:12
  Today we will be discussing seasonal depression and focusing on practical
• 0:17
  strategies for pediatric care.
• 0:20
  Dr.
• 0:21
  Gould, welcome to the show.
• 0:23
  Sara Gould, PhD: Thanks.
• 0:23
  I appreciate being here.
• 0:25
  Mike (Host): What signs should pediatricians look for when screening
• 0:28
  children for seasonal depression?
• 0:32
  And how do these differ from, say, typical winter blues or other mood disorders?
• 0:39
  Sara Gould, PhD: Sure.
• 0:39
  One of the most important things to know about Seasonal affective disorder
• 0:42
  is it is actually a subtype of major depressive disorder, and so it's
• 0:46
  not much different from a lot of the signs that pediatricians are already.
• 0:52
  Looking for screening for in patients.
• 0:56
  And so one piece of it, just like with other emotional concerns, to
• 1:01
  differentiate a bit from something like more of that kind of post-holiday lull
• 1:07
  in mood or things like that, is the severity and the impact of the symptoms.
• 1:12
  So if they're interfering with functioning in life for kids or
• 1:17
  if it's leading to high distress in the child or in their family.
• 1:22
  And so those common symptoms like depression are isolation,
• 1:26
  tearfulness, or irritability.
• 1:29
  A change in academic performance, social interactions, things like that.
• 1:35
  Also, for it to be a true seasonal disorder we do need to see that pattern.
• 1:42
  And so getting sad or more symptoms.
• 1:46
  One early winter season is not quite enough to tip it
• 1:51
  over into that classification.
• 1:54
  Mike (Host): So, What screening tools or protocols do you recommend for primary
• 1:59
  care, and how often should these be used during these high risk seasons?
• 2:06
  Sara Gould, PhD: Screening is always important, especially as
• 2:09
  we're working with young people where new concerns can develop.
• 2:12
  The good news there is that most of the screening tools already commonly
• 2:16
  used in practice such as the PHQ two or nine, are just as effective as
• 2:22
  picking up the symptoms of seasonal affective disorder as general depression.
• 2:27
  The caveat would be to add on that to make a note of what time
• 2:31
  of year did these things start.
• 2:34
  What happened last year around this time or in previous years?
• 2:39
  And then also a good question is, is there a family history
• 2:43
  of seasonal mood difficulties?
• 2:45
  Whether or not seasonal affective disorder itself was diagnosed?
• 2:49
  Mike (Host): Now with, uh, at least pre-teens, you know, maybe into early
• 2:53
  teenage years, during the holiday months, there's a lot going on.
• 2:58
  You got finals and stuff like that at school.
• 3:02
  then they get excited for a Thanksgiving break and a Christmas
• 3:06
  break, but then when they have to go back, I think most kids don't like
• 3:11
  that and seem a little depressed.
• 3:13
  How do you distinguish that kind of stuff from true seasonal depression?
• 3:19
  Sara Gould, PhD: Sure.
• 3:19
  Part of it is looking at again, that impact.
• 3:23
  Are they still wanting to hang out with their friends?
• 3:25
  Are they still interacting with family about the same as grownups?
• 3:30
  Don't necessarily like going back to work right after a good vacation either.
• 3:34
  And so that can be a good convenient comparison as well.
• 3:39
  And to take note of how quickly do kids adjust back.
• 3:43
  Into that school schedule, that routine, and are there things that
• 3:48
  they're looking forward to, or are there even those things that previously
• 3:53
  or typically they enjoy, not so much fun or not as interesting to them?
• 3:59
  Mike (Host): Yeah.
• 4:00
  And I think you made a good point.
• 4:01
  Compare it to the previous year, right?
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  If this is how they usually are during this time, but you know, they get
• 4:07
  over it and they're right back in school and they're with their friends.
• 4:10
  Maybe this is just, not seasonal depression.
• 4:13
  It's just, they were having a great holiday season, right?
• 4:17
  Sara Gould, PhD: Yeah.
• 4:17
  And that can be a really good indicator.
• 4:20
  As always with mental health, part of what we're trying to understand
• 4:23
  is what's going on now for a kiddo, but also how has it changed?
• 4:28
  How has it evolved?
• 4:30
  How does it compare to how they've always been?
• 4:33
  Mike (Host): are the most effective FirstLine interventions for
• 4:36
  seasonal affective disorder in kids?
• 4:39
  Sara Gould, PhD: Two of the most common and the most effective are light therapy
• 4:43
  and cognitive behavioral therapy, which also can be used in combination.
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  So light therapy.
• 4:51
  Is trying to simulate longer day times, which really does have an impact on our
• 4:57
  biology, and some are more susceptible to that impact, and it's to be around
• 5:02
  a light of a certain intensity of 10,000 ls shortly after waking up.
• 5:10
  To be around that light for at least 30 minutes.
• 5:13
  I recommend up to 60.
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  And you don't have to stare at the light.
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  It shouldn't stare at the light really at that intensity, but to glance
• 5:19
  at it once in a while, face it.
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  And so kids can go about their routine.
• 5:23
  They can do it while they're doing their makeup, having breakfast, gathering
• 5:28
  their things, things like that.
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  But that consistency can really help reset some of those biological
• 5:34
  processes that can be protective.
• 5:37
  Against those new difficulties.
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  And then cognitive behavioral therapy is increasing those coping
• 5:43
  skills to be able to manage emotions more effectively overall, which
• 5:49
  can also help in this context.
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  Importantly, light therapy is useful while it's being used.
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  It is not protective in the next season, versus CBT actually can
• 6:01
  be because those skills don't.
• 6:03
  change as the light changes.
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  Another intervention that has support is Bupropion.
• 6:09
  That's the only medication that's specifically labeled for preventing
• 6:12
  seasonal affective disorder.
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  But the other SSRIs are also helpful similarly to other
• 6:19
  presentations of depression
• 6:21
  Mike (Host): Now with the light therapy.
• 6:23
  So these are at home.
• 6:26
  Light boxes basically.
• 6:28
  Right.
• 6:28
  So any advice for parents who, wanna do this for their kids?
• 6:35
  Maybe it's been suggested by their physician.
• 6:38
  how do you know you're buying a good light box?
• 6:41
  Sara Gould, PhD: That is a little tricky.
• 6:42
  I think one important factor that we can depend on is to make sure that.
• 6:48
  The intensity is the right intensity.
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  And so looking for something at that 10,000 lux is a great first step.
• 6:55
  And then talking to networks, looking at reviews, things like that.
• 6:59
  'cause there are a variety.
• 7:00
  There are also even lights, but they're part of a visor, so you
• 7:04
  can wear it around the house.
• 7:06
  The products get pretty creative and unfortunately, like anything,
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  sometimes we have to try a couple to see what fits us best.
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  But that can be really helpful.
• 7:16
  And the side effects are minimal to none.
• 7:19
  And so it can be a low risk thing to try.
• 7:22
  Mike (Host): So the key thing is the brightness, the lux I
• 7:25
  think you said at least 10,000.
• 7:26
  Is
• 7:26
  Sara Gould, PhD: Mm-hmm.
• 7:27
  That's correct.
• 7:28
  Mike (Host): Now, as far as the medication goes do most physicians
• 7:33
  start with light and behavioral and move to the medication if necessary?
• 7:39
  is it truly, you first line for a lot of doctors?
• 7:43
  Sara Gould, PhD: Yeah, that's a great question.
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  I think we use the tools that we have and then we know of, but in
• 7:47
  the literature, light therapy and CBT really are the first line.
• 7:52
  And just caveat, I am a psychologist and so, I'm not in a position to
• 7:56
  make recommendations about dosing or prescribing medicines that
• 8:01
  did wanna make sure to share.
• 8:03
  That one in particular has the labeling for this condition.
• 8:07
  Mike (Host): Yeah.
• 8:08
  How can pediatricians collaborate with families?
• 8:12
  To create, home-based strategies that support mental health
• 8:18
  during, the winter months.
• 8:20
  Sara Gould, PhD: I really appreciate that question because I think holidays
• 8:23
  they're special, but there are so much going on, like you referenced finals,
• 8:28
  all of the theater performances, band concerts, all of those things as well
• 8:33
  as the holiday gatherings and parties gets piled into really a very short time
• 8:38
  period, and that is fun and stressful.
• 8:42
  Also, for some families, holidays have hard memories associated with
• 8:47
  them, and they're bringing that past into this season as well.
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  And so one really important thing to be mindful of is to
• 8:56
  set realistic expectations.
• 8:59
  We can't do everything.
• 9:01
  Maybe if we're dealing with something this season, we can't fit in all of
• 9:05
  the traditions that we're used to.
• 9:07
  So can we prioritize?
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  Can we talk together as a family about what we're going to include
• 9:12
  this season and what we are not?
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  And to be really mindful of overcommitment, both because of the
• 9:18
  hassle and stress that and juices, but also because that can impact
• 9:23
  sleep and all of us are at more risk if we're not getting enough rest.
• 9:29
  Another piece of that can be to make sure that we're prioritizing connection
• 9:34
  over kind of just numbing activities.
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  So an example of that is even if we just limit the discussion to screens,
• 9:42
  watching a movie together or playing a video game collectively is very different
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  from everyone sitting in the room on their own device doing their own thing.
• 9:51
  Finally, I would suggest with these short days make the most of the daylight there
• 9:56
  is, so thinking about scheduling certain activities at certain times where we
• 10:01
  all get the most exposure that we can.
• 10:05
  Mike (Host): that was some fantastic advice.
• 10:07
  Of course, the hard part about getting that sunlight is if you live in a
• 10:10
  really cold place, that's tough.
• 10:13
  Sara Gould, PhD: It is.
• 10:13
  And so even in those times that we can make use of our windows or car rides or
• 10:19
  bundle up and check which part of the day is gonna be the warmest and be out even
• 10:24
  for 15 minutes can make a difference.
• 10:26
  Mike (Host): Now let's talk a little bit about teachers, school performance
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  and pediatricians obviously.
• 10:35
  Kids with seasonal affective disorder with specifically depression, their performance
• 10:41
  isn't gonna be maybe where it should be.
• 10:45
  So how should pediatricians work with teachers?
• 10:48
  Sara Gould, PhD: Yeah.
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  This is another area that is similar to other types or presentations of
• 10:52
  depression because you're right, if our mood is hard, if motivation is really.
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  A tough fight to gain.
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  Then academics are gonna take a hit most likely, as well as
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  social functioning at times.
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  And there are a lot of academic demands in this part of the year.
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  And so asking for things like when possible, a reduced workload, for example,
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  in algebra, if the student can do five of the 10 assigned problems perfectly.
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  Could we skip the other five?
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  Asking for things like extended deadlines or for coping breaks in schools.
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  Being able to step out of the situation briefly, take some breaths, use some
• 11:36
  skills, and be able to step back into it.
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  Those things can make a big impact.
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  I also think the more everyone, parents, pediatricians, educators,
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  coaches can communicate that the focus should be on effort.
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  Or a process, an experience over performance, that can be really helpful
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  because there are so many evaluative situations and experiences piled
• 12:04
  on each other in these few weeks.
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  Mike (Host): in your experience, do you find that schools, teachers,
• 12:11
  administrators are more open in today's world to extending deadlines, as you said,
• 12:19
  maybe shortening some of the homework?
• 12:23
  Or is that a, challenge?
• 12:25
  Sara Gould, PhD: I think most schools are pretty aware these days
• 12:27
  that our kids are struggling in a lot of ways, and that everybody
• 12:31
  needs a helping hand at some point.
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  Including US adults.
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  And so part of it schools know best what resources they do have, and so
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  it's great to have a communication style that is focused on what is the goal
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  rather than a particular accommodation.
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  We can suggest them, but to also be very open to what can schools
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  offer, what do they already have?
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  Readily available that they can slide in quickly for kids and that might
• 13:02
  change depending on the school, their personnel, the resources, et cetera.
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  But yes, most schools are very open to these conversations and really
• 13:12
  are interested in how helping kids succeed and these conversations
• 13:17
  help them know how to do that.
• 13:20
  Mike (Host): When we look at risk factors specifically, I want to talk about
• 13:25
  family history and coexisting conditions.
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  Is there a family history, and I think you touched on this a
• 13:33
  little bit at the beginning.
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  Is there a family history connection here to seasonal depression?
• 13:40
  Sara Gould, PhD: There is like most mental health concerns.
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  There seems to be genetic or biological vulnerability that doesn't automatically,
• 13:48
  a condition will present itself or that the same condition will present
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  itself in a child as in a relative, but it does increase the risk or
• 13:57
  can help us know what to look for.
• 14:00
  And so knowing that family history.
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  Again, even if it's not diagnosed, some families will say like, oh yeah,
• 14:07
  I always have trouble in January.
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  Okay, let's take note of that and ask a few more questions to understand
• 14:13
  what that looks like and if that could have implications for our patient.
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  Some other things to consider is one kids or teens that already
• 14:24
  are dealing with depression.
• 14:26
  It might not be labeled as seasonal affective disorder
• 14:29
  if it happens year round.
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  But the season or the change in light can have an additive effect, and so they might
• 14:36
  need additional support this time of year.
• 14:40
  And one thing to note too is daylight is linked to this.
• 14:44
  And so the farther north a family lives or a provider's practicing,
• 14:50
  there is increased risk of these disorders versus farther south.
• 14:55
  Mike (Host): now coexisting conditions.
• 14:57
  Can we run through that again?
• 14:59
  Like, Are these connected to.
• 15:00
  Some other mood disorders throughout other seasons, et cetera.
• 15:05
  Sara Gould, PhD: Yes, it's primarily related to depressive disorders,
• 15:09
  whether that's DYS or the various versions of major depressive disorders.
• 15:13
  However, bipolar disorder can also have a seasonal subtype.
• 15:18
  So that is a condition, certainly more rare in kids, but to be aware of that.
• 15:24
  Mike (Host): And when should pediatricians refer?
• 15:28
  Patients to a mental health specialist like yourself.
• 15:31
  Sara Gould, PhD: Sure.
• 15:32
  One thing to remember, and I do think pediatricians are very aware of this,
• 15:36
  is it should not be the generalist's burden to sort everything out.
• 15:41
  And so if there's a question that is a fine, a totally appropriate time to
• 15:46
  refer, to get a mental health person in there to help sort out the details and
• 15:51
  help select the best evidence-based.
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  Interventions based on the concerns and also the family situation, resources,
• 16:00
  all of those things to be able to individualize care in that way.
• 16:04
  And definitely if there is impact on family or other domains of functioning
• 16:10
  for a child, that would be a really good time to pull in some additional resources.
• 16:16
  And the care itself looks very similar to that.
• 16:19
  Of just care for depression, with the exception of course of the light therapy.
• 16:24
  So again, recommending therapy, ideally cognitive behavioral
• 16:28
  therapy, families can find those light boxes online pretty easily.
• 16:33
  And then considering if for this patient, medication might be an additive help,
• 16:39
  whether that is managed by the PCP.
• 16:42
  Or referred on to psychiatry or something like that.
• 16:45
  And please also do remember Children's Mercy.
• 16:48
  Psychiatry is available for consultation if pediatricians would like to
• 16:52
  run a case by them, particularly as pertains to medication use.
• 16:56
  Mike (Host): Dr.
• 16:57
  Agul, this has been fantastic.
• 16:58
  I'm very impressed with the amount of information that you share
• 17:02
  today, so thank you so much.
• 17:04
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• 17:10
  slash CME podcast.
• 17:12
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• 17:17
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• 17:22
  This is Pediatrics and Practice.
• 17:24
  I'm Dr.
• 17:25
  Mike.
• 17:26
  Thanks for listening.