“Hi Dr. Nicole, Thank you for your great blog! I love your recipes. My depression is much worse this time of year. Why am I more depressed in the winter? What do you recommend?”
Tara M. Scottsdale
Prescription: Vitamin L 10,000 Lux
"Vitamin L" or Light in the form of "Lux" is very important in seasonal depression. Depression patients need to schedule their outdoor time when the sun is out or invest in a lightbox.
During these dark times, we are exposed to less light. Light is needed by the brain to produce serotonin. Serotonin is needed for a happy calm mood without depression, anxiety, panic, or worrying. Deficient serotonin can lead to loss of sleep at night. The next day you wake up tired and even more depressed and the Vitamin L deficient cycle continues on and on progressively getting worse with each winter month. With less light, most depression patients already low in serotonin feel much worse. You should ensure you are getting at least 1 hour of time outside if you battle seasonal depression or "Seasonal Affective Disorder" aka SAD.
Ideally, for my depression patients, I want them outside walking or doing something active one hour twice a day to optimize their neurotransmitter production. If you are depressed and also struggle with chronic pain or an autoimmune condition like I have and can't always exercise, at least plan to sit outside twice a day in a sunny patch in your yard or drive to a park. Chronic pain patients that cannot exercise still need to get outside and get fresh air and sunshine.
Whether you have depression just during the winter months, or whether you struggle with depression all year round that is exacerbated by the low light conditions of winter; having a solid plan in place to better cope with the realities of winter depression is an important preventative measure.
My last name SUNDENE serves as the perfect mnemonic to help remember how to take care of yourself throughout the winter months. These are the basics to be doing for patients with seasonal depression along with connecting with their counselor or therapist by zoom or in person. Most decent insurance plans cover counseling so please enroll in counseling and have someone help you manage your depression if I am not your personal "Holistic Psychiatrist."
If you live in Arizona like I do it is easy for me to get plenty of "Vitamin L" and take a walk outside or schedule reading and other activities like phone calls and zoom meetings outdoors. If you live in a low light Northern Latitude like I did in Seattle you will find that using a lightbox twice daily can be enough to boost your mood like a medium to low level anti-depressant so that you feel happy on less medicine.
Let's make light a mandatory part of every depressed patient's mental health program!
The Sundene Protocol for Seasonal Affective Disorder
“Sun” – We need 10,000 lux of light every day in order to produce enough serotonin to feel happy. This can be achieved by 15 minutes outside on a BRIGHT BLUE sky sunny day, or 1 hour outside when it is overcast. You may wonder “What in the world is a lux?” A lux is the light equivalent put off by one candle. So you can light 10,000 candles in your home to cheer yourself up (a bit of an expensive fire hazard!) or you can just invest in a lightbox on Amazon or at a local sun shop. When I first bought a lightbox I bought the least expensive one that only put off 5000 Lux per hour and quickly realized it was very time consuming for me to spend so much time in front of a lightbox. However to save money, if you sit at an office desk all day this IS a feesable option.
A lightbox is an excellent idea for those with seasonal depression and is best used for twenty to forty minutes in the morning and afternoon depending on the manufacturer’s recommendations to achieve the 10,000 lux equivalent. What I did not understand when I first purchased one is that the Lux is generally per hour. So most that emit 10,000 Lux require you to use them for one hour. Therefore to get 10,000 Lux from the 5000 Lux Lightbox
If you are unable to afford a lightbox you can simply try full spectrum light bulbs as these often provide enough light for those with mild to moderate seasonal depression. Keep your windows open and move your desk or work station to natural light or a lightbox if you are depressed and aim for twice a day so your body can optimally make serotonin.
Don't use your lightbox before bed or it will keep you up as serotonin needs to be converted to melatonin which happens as our natural light goes down in the evening. Using a lightbox right before bed may upset your sleep and throw off your 24 Hour Circadian Rhythm resulting in hormone imbalance. So I don't recommend using a lightbox for depression right before bed.
The best winter options are near water or snow in beautiful settings in order to visit during the gloomy months of winter as the light is intensified as it is reflected back up to our eyes. If you are concerned about protecting your eyes from UV radiation, you can buy sunglasses with a clear or light lens, but that still provide UV filtration as it is the actual photons of light that our brains use and not UV radiation to produce serotonin.
Those struggling with seasonal depression need to make an appointment with the sun or the sun’s substitute via a lightbox every single day. Topping off your serotonin levels by day means that more of this neurotransmitter will be available for conversion to melatonin (the hormone that keeps us asleep at night). Using light as medicine should easily improve your sleep, leaving you more energetic for the following day.
“D” -Vitamin D is no longer considered a vitamin, but a “pro-hormone." Vitamin D is produced in our bodies when UV light touches our skin. Most people living in the northern latitudes are easily vitamin D deficient if they do not spend 20 minutes outside each day. Vitamin D is an important mental health vitamin we can test with lab metrics to ensure your dose is optimal. Some patients need more than 2000 iu and some patients may have toxicity at higher doses.
Elderly people are more at risk for depression because they have thinner skin, and thus produce less vitamin D, they also absorb less dietarily. If you struggle with depression, it only makes sense to be sure that you are at least not deficient in vitamin D. If you care for a senior in a care facility make sure they are wheeled outside twice a day in the morning and afternoon so they can receive natural light that is important for their bones and mood.
The RDA of Vitamin D for women is 800 IU. Food sources of vitamin D are milk, fish, and yeast. I typically recommend 2000 IU of vitamin D for my patients struggling with depression as a cheap and easy insurance policy that they are not deficient in vitamin D since it is also important to boost the immune system.
If you would like to have your levels checked be sure that your physician orders the “25-OH-D” as that is the most reliable indicator of vitamin D stores. Do not ever exceed 5000 IU of vitamin D daily unless under the care of your Naturopathic Doctor. Dangerous side effects such as hypercalcemia can occur. Be sure to have your vitamin D levels tested every 6 months so you are in an optimal range between 50-80. Levels above 100 are considered vitamin D toxicity. Too much Vitamin D can cause high calcium in the blood and can be dangerous. Please do not overdose with vitamin D as I am seeing a lot of toxic levels come through right now. It is critical the vitamin is dosed properly.
“E” -Exercise- is the drug of choice for anyone that is depressed. It is a tough medication to take though when depressed because as best summed up by Newton’s laws of motion: “An object at rest stays at rest until acted upon by another force.”
I know as someone that has personally struggled with depression that when you are down in that dark depressing hole it is tough to get exercising, but stagnation is just going to perpetuate your problem. I tell my depressed self that refuses the concept of the walk, "You can be in just as bad of a mood on your walk," and usually going on the walk results in a lifting of my mood. Worst case scenario you are in just as bad as a mood when you started. Rarely does exercise not help lift my patient's moods. Too much time indoors right now is affecting people mentally and physically so please get outside and walk, bike, hike, play tennis, swim, play basketball, ski, snowboard... if you are depressed it is your job to figure out which TWO sports you are going to be doing for fun, fitness, and light. I will let you pick! Rotate the two sports every other day and give yourself one rest day per week if you need it. By planning to exercise every day patients are more likely to achieve the 5 days of exercise a week that is optimal for mental and physical health.
Countless studies support the efficacy of exercise for depression. If you struggle with seasonal depression be sure to try to exercise outside EVERY SINGLE TIME the sun is out! Find a walking, running, or cycling buddy and take turns pushing each other out there. Put your exercise equipment in your backyard as a temporary gym and exercise outside in the light.
Whatever you do…just keep moving! Being cramped up indoors during the winter months is the problem and not the solution. Your brain needs to go on a walk every day. The best way to be successful with exercise is to schedule it and plan to walk or bike at the same time every day. I like to walk my Golden Retrievers first thing in the morning while I sip my tea, and mountain bike after work. I plan my exercise at the same time every day, twice a day, and follow the routine even when in a bad mood because as a Naturopathic Doctor I know that exercise is the best medicine for my brain. Plus it is free and when you look fit and healthy you also feel happier. If you are having trouble making decisions because your depression is that severe following your mental health daily schedule is very important. Some of my depression patients are so depressed they cannot decide where, when and what to do for their exercise that is why following a daily and weekly fitness schedule is imperative for depression patients.
“N” –Nutrition is fundamental for anyone struggling with depression. When the body does not feel good the mind is soon to follow. Depressed thinking often results in poor dietary choices.When we are depressed and in a low light setting we crave carbohydrates so that the body can produce more serotonin.
However, sugar is exactly what the body does not need in the long term for healing from depression. The best diet for those with depression, anxiety, and bi-polar to follow is my PGE-2 Diet as it is high in the Omega-3's mental health patients need, is high in protein for amino acids and also improves inflammation. You will also receive yoga and mediation videos that are only 10-15 minutes to do and easy to reset your brain and adrenals. Did you know multiple studies show a link between depression, anxiety and inflammation? When I started seeing my PGE-2 Diet improve my patient's moods, I realized how important this inflammation link is!
Protein is mandatory for depression patients. Female depression patients, in my experience as a naturopathic doctor are generally all eating very low protein causing their brains to be starved of the necessary amino acids needed to form hormones and neurotransmitters that help us feel happy such as tryptophan, taurine, and tyrosine. The thyroid needs tyrosine to make hormones and T3 is needed to make serotonin in your brain so not eating enough tyrosine foods can cause depression. Serotonin is formed from tryptophan which is why we give patients 5-HTP as an amino acid therapy precursor to boost serotonin levels. Eating a diet of all carbs is very common for my depression patients. We crave carbs because carbs give us a quick boost of serotonin, but then that goes away and is not sustainable when we lack a constant supply of amino acids needed for mental health.
Balancing your blood sugar will also help keep the mood at an even keel throughout the day. Be sure to eat protein and fiber with every meal to prevent low blood sugar crashes that can trigger depression, anxiety, and panic attacks. Especially focus on eating foods high in tryptophan such as turkey, cottage cheese, peanuts, fish, eggs, oatmeal, avocados, and bananas. Patients with Bipolar Depression may boost mania by eating some of those foods so please work with a Naturopathic Doctor experienced in these matters such as myself!
A high quality multi-vitamin will cover all the bases and ensure that you are not deficient in any of the B vitamins that are coenzymes for producing the neurotransmitters that make us feel happy. Be sure the b-vitamins are ACTIVE and not SYNTHETIC GARBAGE like Centrum or Flintstones vitamins. Synthetic vitamins will only make it worse. Invest in quality for your brain. Taking a high quality multivitamin is a simple and inexpensive thing to do that is especially important in Women's Health as low iron levels are the #1 thing I find causing anxiety, depression, sadness and chronic fatigue in women. Because women are losing blood every month it is important they replete iron stores sufficiently for anxiety, depression, and mental health.
My depression patients are also often deficient in Omega-3 Fatty acids from fish oil, flaxseeds, walnuts, chia seeds, or algae. That is it. There are essentially no other sources of Omega-3's and any other nuts or oils are full of omega-6 and omega-9 that can increase inflammation. Since there is a link between increased inflammation and depression and anxiety it is imperative that patients take a supplement of Omega-3's if they don't like the food sources. When I learned about this I realized that my severe aversion to fish is part of why I am prone to depression and simply taking a high dose fish oil every day was a huge game-changer for me. Those are the only sources of Omega 3's. Unless you are allergic to fish the active form of Omega-3's in fish oil will be more beneficial to your mood than vegan sources as the vegan source has to be converted to the active form which is a biochemical step that some people genetically lack the genes to make this conversion such as Scandinavians like myself.
“E” -For Everything Else please work with a doctor on your individualized care plan. There are many treatment options for depression. I could go on and on about amino acid therapy, herbal medicine, genetics and nutrition related to depression but it is important you work with someone overlooking your big picture. My most successful mental health patients in my practice work with me closely for 3-4 months checking their hormones, vitamins and amino acids related to their depression. They keep me updated with what is working and what is not working at monthly appointments until we have an effective treatment plan. As a Naturopathic Doctor I have helped many patients off of their anti-depressants but it is a process that requires we add in all of the correct nutrition and natural medicines first and then after a few months we gradually wean down the anti-depressant. Depression patients should never suddenly stop taking their anti-depressants. As a Naturopathic Doctor I really don't have a problem with anti-depressants. They are not a drug I see causing long-term effects that I find dangerous. The real problem with them is when they simply do not work because something is wrong with the patient and they don't make enough serotonin for instance to be recycled by the anti-depressant. By working closely together for a few months we can study your personal weak spots and target nutrition directly towards the weak spots to strengthen your mental health. Eventually I work my way out of a job when my mental health patients improve and they no longer need me.
Stay tuned for my blog on Neurotransmitter Testing as this was very helpful for me. Knowing that my body struggles to make serotonin and other neurotransmitters that calm the brain was a relief to know!
Please do not give up hope, I am providing an overview of what I do for depression patients so you do not ever give up hope. Rarely can I not help patients. The only patients I cannot help are the ones too depressed to follow their care plan. If you are in this boat you need someone to help you facilitate the plan for it to be effective and I reccomend bringing your Mom or Husband to your appointments, or have them listen in on your Telemedicine calls so they understand what you need to do. Be sure to implement the basics for your seasonal depression above and work with your doctor or book a visit with me below.
Counseling, herbs, amino acids, and of course anti-depressants when needed will help keep you out of that dark “hole." Naturopathic treatments for depression often take time as they are addressing the whole person and the long term.
As a physician, I give every depression treatment plan 2 to 4 weeks to determine its efficacy. Natural medicines take time to work. This is why I recommend monthly visits for mental health patients. Even a prescription antidepressant takes 2 weeks to work. If you are not experiencing improvement you may want to consider other treatment options but please don't throw away the depression treatment too soon. Too many of my depression patients have tried something for ONE DAY and then felt depressed and hopeless that the natural medicine did not work. We need to have realistic expectations for mental health. The same rules for Naturopathic Medicine apply to medications and you need to try something for at least a few weeks to give it a chance.
Various counseling and therapy techniques are also available to teach you how to cope and self-soothe, if you find you are not making progress with your therapist, consider a new referral for a different type of therapy such as EMDR or tapping. Sometimes talking about your problems can only get you so far and we need to focus on coping tools.
Remember that aside from physical and mental components, there is also a social component to seasonal depression. Much time spent inside, or repeatedly with the same people inside can contribute to a poor mood. Schedule weekly activities to get you out of the house and interact with others. If your relationship is struggling schedule yourself away to give everyone a break. Absence makes the heart grow fonder!
Did you know I have had to provide a lot of marriage counseling during the Pandemic for my patients? Everyone is struggling with too much time spent together. I promise you are not the only one!
If you live alone, the winter months can feel especially isolating. Find an elderly person that also lives alone to check in on, it will do you both a world of good. Many of my seniors are struggling with loneliness and it would be great if you could check on them for me. They need their neighbors to chat with them. It is okay to not feel your best right now. We have all been through a lot. It is very normal to feel down and depressed. After 22 years of working in Family Medicine, I have never seen people more sad, angry, frustrated, distressed, and depressed.
IF you need help looking at your hormones and nutrition related to your anxiety, depression or mental health challenges pop over to my appointment SCHEDULE page and book a visit. A lot of what I do is diagnostic if you are not in Arizona, we can still use Telemedicine to order your labs and work together to determine if your female hormones, thyroid, adrenals, and nutrition are all properly balanced or not. Herbs and supplements can still be prescribed to those out of state.
Ladies, as a Female Hormone Specialist I can assure you that female hormone imbalance is often the root cause of your mental health issues. Please remember mental health challenges like anxiety, anger, and depression in women that fluctuate monthly indicate high estrogen levels as seen with PMS. Feeling blah, depressed, lifeless and in a constant tired fog can be from imbalanced adrenal hormones or thyroid disease. Mental health challenges in women that start in the 30-40's can start because of low progesterone, perimenopause or pre-menopause. Sudden depression or anxiety that occurs with loss of estrogen in menopause can be treated with herbal medicine or bio-identical hormones. It is important if your body is changing with age that we get answers.
Thank you for your great Naturopathic Women's Health questions! Please continue to send them to my clinic address below on a postcard! I love to get something in the mail that is not a bill. Remember if your question can't fit on a postcard you need to schedule an appointment with me HERE.
Dr. Nicole Sundene, NMD
Dr. Sundene is a Naturopathic Doctor in Scottsdale, Arizona, and is considered a Female Hormone Expert in Women's Health and Bioidentical Hormones. She specializes in Holistic Women's Health for Menopause, Thyroid, Hashimotos, PMS, Perimenopause, Autoimmune, Postpartum Depression, Chronic Fatigue, Depression, Anxiety, Food Allergies, Digestion, Dermatology , Acne, Psoriasis, Eczema and Adrenal Hormonal Conditions. In 1999 she began working for a Hormone Doctor prior to starting Naturopathic Medical School. With over 22 years of experience in both Prescription and Natural women's health and hormones, she presents to women the best-integrated health solutions for their Chronic Disease. She has been an Herbalist for over 27 years and enjoys teaching women how to use herbs to balance their hormones, nutrition and optimize their health. Dr. Sundene relies on blood testing for her hormone metrics. The hormone testing is covered per the patient's insurance plan and conducted at certain points in the woman's menstrual cycle. To learn more about Hormone Testing for Women Visit: Bioidentical Hormones. Follow Dr. Sundene on Instagram, Twitter, and Facebook for more tips on Women's Health, Female Hormones and Naturopathy!
