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Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy

International Physical Medicine & Rehabilitation Journal
Vitamin D for Depression with a Seasonal Pattern: an
Effective Treatment Strategy
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Low level of vitamin D has been linked to the symptoms of
recurrent major depression with a seasonal pattern [1]. Vitamin
D is a fat soluble vitamin, also referred to as the sunshine vitamin
obtained from natural sunlight exposure to skin [2]. Sunlight
has the ultraviolet- B (UVB) photon rays that promote vitamin D
    
        
cereals, etc.) are enriched nutritional sources of vitamin D [4].
Seasonal affective disorder (SAD), in accordance with DSM
        
depressive disorder with a seasonal pattern, which is a variant
of depression that occurs during fall and winter seasons, often
referred to as winter blues or seasonal depression [5,6]. Duration,
frequency, and severity of these depressive disorders vary with
geographical latitude, temperature and climate [7]. Depressive
symptoms associated with low level of vitamin D include
depressed mood, irritability, frequent crying spells, tiredness,
social withdrawal, decreased energy levels, appetite and sleep
disturbances [8,9]. Atypical symptoms of depression including
Volume 1 Issue 4 - 2017
Department of Pain Management Center, United States Army
Institute of Surgical Research, USA
*Corresponding author: Sonali Sarkar, Interdisciplinary
Pain Management Center, Brooke Army Medical Center,
United States Army Institute of Surgical Research, USA, Fax:
78234; Email:
Received: May 25, 2017 | Published: August 09, 2017
Review Article
Int Phys Med Rehab J 2017, 1(4): 00021
Background: Low level of vitamin D is often associated with major depression
with a seasonal pattern, formerly known as seasonal affective disorder under the
DSM IV classification. Major depressive disorder is commonly observed during the
fall and winter seasons in countries away from the tropical zone and is referred
to as depression with a seasonal pattern under the DSM V classification. Here, we
conduct a review of literature to address the factors highlighting the association
between vitamin D level and depression with a seasonal pattern.
Objective: 1) Review the epidemiology, etiology and pathogenesis associating
vitamin D level and depression. 2) Provide treatment recommendations
and practice guidelines for addressing vitamin D deficiency associated with
depression with a seasonal pattern.
Methods: Literature review on human studies published in English language
from 2000-2017 using PubMed, EBSCO, and Google Scholar was performed.
Results: Majority of published studies have associated low level of vitamin D
to depression with a seasonal pattern. A high prevalence of major depressive
disorder is observed in Northern latitude countries with severe, prolonged
winter that experience little or no sunshine available within the wavelength that
is necessary for cutaneous synthesis of vitamin D. A review of literature indicated
that reduced exposure to sunlight is associated with low levels of vitamin D,
decreased serotonin activity, an increased production of melatonin, and changes
in circadian rhythm. Associated factors include socio-demographic (older age,
female, higher BMI>25Kg/m2, geographical location), and clinical correlates
including chronic pain, comorbid neuropsychiatric conditions, chronic diseases
(hypertension, diabetes mellitus, autoimmune disorder), and musculoskeletal
disorders. Treatment recommendations include light therapy, antidepressant
treatment, psychotherapy, melatonin and vitamin D supplementation. Among
all the modalities, vitamin D supplementation is an effective preventative and
treatment strategy for the management of depression with a seasonal pattern.
Conclusion: Sunlight exposure within the recommended wavelength promotes
vitamin D synthesis from cholesterol in the skin. Vitamin D deficiency is observed
among adults especially those residing in sunlight deficient geographical
locations. Among vitamin D deficient individuals suffering from major depression
with a seasonal pattern, early detection and vitamin D supplementation can be a
simple, convenient, and cost-effective treatment strategy for improving symptoms
and mental health outcomes associated with major depression.
Keywords: Vitamin D; Depression; Seasonal Affective Disorder; Prevalence;
Citation: Sarkar S (2017) Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy. Int Phys Med Rehab J 1(4): 00021. DOI:
Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy 2/10
©2017 Sarkar
hypersomnia, carbohydrate craving, increased appetite, weight
gain and extreme fatigue are also common [10]. Similar to all
depressive disorders, feelings of self-harm, suicidal ideation or
tendencies are observed in individuals with major depression
with a seasonal pattern [11].
Vitamin D and sunlight are effective not only in the management
   
including prevention and treatment of osteoporosis, arthritis,
     
cardiovascular diseases, chronic diseases such as type 2 diabetes
mellitus and certain forms of cancers [12,13]. Therefore, the active
form of vitamin D, referred to as 1, 25-dihydroxycolecalciferol
(vitamin D3) is often used clinically for the prevention and
        
the epidemiology, etiology and pathogenesis highlighting the
association between vitamin D level and depression with a
seasonal pattern. Additionally, treatment recommendation and
 
associated depression with a seasonal pattern is provided with an
emphasis on vitamin D as an effective preventative and treatment
Online databases (PubMed, Medline, EBSCO, Psychinfo)
along with articles from Google scholar were searched from
2000-2017. Only articles published in English language
were included. Key reviews and original research articles for
adult population were included using the terms “vitamin D”,
“recurrent”, “major”, “depression”, “seasonal”, “pattern, “seasonal
affective disorder, “symptoms”, “psychiatry”, “neuro-psychiatric”,
“depressive disorder”, “etiology”, “prevalence”, “epidemiology”,
“pathology”, “pathogenesis” , “clinical”, “practice”, “treatment”,
“recommendations”, “guidelines”. These search terms were used
in combination with each other using the conjunction “AND”
and “OR”. The search was supplemented by a manual review
of the reference list from relevant articles. The search yielded
more than 400 articles. A total of 229 articles were included for
the initial review. Articles were excluded for duplication, animal
studies, laboratory or preclinical studies emphasizing on the
molecular structure, physiology, biochemistry, pharmacokinetics
or pharmacodynamics of vitamin D. Only, 129 articles that were
recent and clinically relevant to the topic and subheadings were
Majority of published studies have associated low level of
vitamin D to depressed mood and major depression with a
seasonal pattern [15]. Prevalence of depression with seasonal
pattern is approximately 10% in Northern latitudes and ranges
from 1.5-9% depending upon the latitude [16]. In the general adult
population, prevalence varies between 0.4-16% based on latitude,
age, gender and other lifestyle factors [17]. Prevalence reporting
or underreported and consequently undiagnosed [18].
Systematic reviews and meta-analytic studies indicate lower
vitamin D levels among patients suffering from depression
compared with controls with increased odds ratio of depression
for the lowest vs. highest vitamin D categories [19]. One study
      
with categorically low levels of vitamin D. For example., in a
sample of older adults >65 years, prevalence of depressive
symptoms was 22.6% with vitamin D-25(OH) D levels of <30
ng/mL (85.4%); prevalence of depression increased to 25.8% in
participants with lower 25(OH)D levels of <20 ng/mL (51.4%);
and a greater increase in the prevalence of depression noted to
be 35% in participants with lowest 25(OH)D levels of <10 ng/mL
(9.8%) [20]. Another study conducted by Spedding [21] examined
      
association of vitamin D level and depression and indicated that
          
management of depression.
      
risk/hazard ratio of depression for the lowest vs. highest vitamin
D categories [19]. Conversely, one study found no association
        
elderly Chinese participants from Beijing and Shanghai [22].
Epidemiologic studies associating vitamin D level and depression
are mostly cross-sectional and provide mixed results. Due to
the research methodological limitation including study design,
sample size, lack of control of confounding factors and other
        
association vs. a circumstantial evidence between vitamin D level
and occurrence of depression [23]. Nevertheless, majority of the
studies support an association between low levels of vitamin D
and depression.
Etiology and pathogenesis
The exact mechanism involved in the etiology and pathogenesis
of vitamin D and depression is not known. A review of literature
indicated that reduced exposure to sunlight is associated with
decreased serotonin activity, low vitamin D level in the body, an
increased production of melatonin by melanocytes in the skin,
and changes in circadian rhythm [24,25]. One study reported that
with serotonin production rate by the brain (r=0.29, p=0.10) that
rises rapidly with increased luminosity and conversely, serotonin
turnover by the brain is lowest in winter (p=0.01) [26]. Altered
regulation of neurotransmitter serotonin that maintains mood,
 
       
binding receptor is observed among patients with depression
with a seasonal pattern [27]. Depressed patients exhibit 5% more
serotonin receptor transporter (SERT), in winter months than in
summer [28]. Since SERT transports serotonin from the synaptic
cleft to the presynaptic neuron, therefore, higher SERT levels lead
to lower serotonin activity [28]. During summer, sunlight keeps
SERT levels naturally low but in fall and winter season as sunlight
diminishes, a corresponding reduced brain serotonin transporter
availability and consequent decrease in serotonin activity occurs,
as noted by imaging, thus causing low mood symptoms and
depression [29].
Citation: Sarkar S (2017) Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy. Int Phys Med Rehab J 1(4): 00021. DOI:
Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy 3/10
©2017 Sarkar
Alteration in melatonin production affecting the normal
biological circadian rhythm is often associated with depression
with seasonal pattern [30]. Melatonin is also known as the
darkness hormone and is produced by the pineal gland that
responds to darkness by causing sleepiness consequently high
levels of melatonin are found at night vs. low levels during daytime
[31]. During shorter days of winter, as days become darker,
melatonin production increases and makes people sleepy and
lethargic, affecting their circadian bio-physiological rhythms with
altered sleep/wake cycle, thus causing some people to become
depressed [24].
Circadian rhythms also known as the body’s internal biological
24-hour clock are entrained to respond to rhythmic dark-light
changes that occur at certain times during the day and in each
season [32]. Among people suffering from depression, the
circadian signal that indicates a seasonal change in day length is
timed differently that makes the individual physiological response
mechanisms (sleep wake cycle, cortisol release and related
   
[33]. Therefore, studies highlight a biological model comprising
of a combination of decreased serotonin and increased melatonin
impacting circadian rhythm in patients suffering from depression
with seasonal variation.
as observed in countries with severe, prolonged winter is
associated with the pathology of various health conditions [34].
Broad-spectrum phototherapy, with wavelength between 280-
320 nm as obtained from sunlight, enables skin to produce vitamin
D from cholesterol [35]. In the absence of light wavelength, within
         
of vitamin D combined with less outdoor activities and also
covered clothing that prevent exposure to sunlight on the skin
consequently results in low serum levels of vitamin D [35]. Also
a relationship between depression and serum levels of 25(OH) D
depression among very low and low vitamin D groups compared
to optimal and normal vitamin D groups after a blood draw
in a cohort of individuals with cardiovascular diseases above
50 years. Vitamin D level is reported to be inversely associated
with depression [37]. Therefore, these factors as described by
published studies provide biological evidence implicated in the
pathogenesis of low vitamin D level and depression with seasonal
pattern. Other associated factors include
Socio-demographic factors
Population data obtained from 2005 health survey from
England indicates that the demographic predictors including
older age >65 years, female sex, non-manual socio-economic
class, overweight individuals with higher body mass index (BMI
>25 Kg/m2 ), and those with long standing physical illness often
exhibit depression associated with low vitamin D level [20].
However, in young adult US population (aged 15-39 years), data
from the third National Health and Nutrition Examination Survey
(NHANES) indicated that women, non-Hispanic blacks, people
living below poverty, individuals with higher BMI, persons not
consuming supplements, people living in urban areas and in the
Southern and Western regions of United States and those with
current depression have a higher odds (OR=1.85; p=0.021) of low
obese subjects with vitamin D level below 40 nmol/L have higher
depressive scores on the Beck’s Depression Inventory (BDI)
compared to those with vitamin D level more than 40 nmol/L [39].
Traditionally, sun deprived countries with cold climate that
are geographically located in higher Northern latitudes (Canada,
North America, Europe) away from equator have been associated
         
sunny environment from countries including Israel, Saudi Arabia,
Florida (USA), Australia, New Zealand, Brazil, India, Lebanon and
Jordan [40-43] Studies from Asian and Middle Eastern countries
a sunny environment that is partly attributed to customary
traditional clothing that covers the entire body and poor outdoor
activities thus not enabling photosynthesis of vitamin D to occur
from melanocytes in the skin [43-46]. Additionally genetic
differences, phenotypic skin melanin pigmentation, ability to
absorb UVB radiation, cutaneous synthesis of vitamin D are
individual demographic differences that contribute to vitamin D
       
metabolism that is associated with physical and mental health.
Clinical Correlates
Chronic pain
Vitamin D exerts anatomical, hormonal, neurological and
      
mediators including neurotransmitters, neuropeptides,
hormones and cytokines [48]. Vitamin D increases serum calcium
which is essential for muscle contraction, protein synthesis that
affects muscle growth and function [49]. Consequently, vitamin
  
myopathy [50,51]. Low vitamin D level is prevalent in patients’
with chronic low back and musculoskeletal pain [52-55]. Among
     
pain is associated with hypovitaminosis D [56]. Similarly, in a
longitudinal European male ageing study, patients who were pain
        
        
for those with low vitamin D level [57]. Women are commonly
affected with low vitamin D associated chronic pain condition.
For example; one population study reported that low vitamin D
concentration associated with CWP is reported in middle aged
British women [58].
Chronic pain patients often suffer from depression that
is unresponsive to antidepressant therapy [59]. Treatment
resistance to standard antidepressant therapy in chronic pain
patients can be due to low levels of vitamin D as an underlying
cause for depression that often goes undiagnosed and untreated.
In this context, one randomized, double-blind, placebo-controlled
study indicated that vitamin D supplementation in major
Citation: Sarkar S (2017) Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy. Int Phys Med Rehab J 1(4): 00021. DOI:
Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy 4/10
©2017 Sarkar
effects on depression scores compared to the placebo group [60].
Clinical research studies indicate that low level of vitamin D is
associated with chronic pain and comorbid depression [61,62].
  
         
therapeutic effect but also prevent disease progression.
Neuropsychiatric condition
Vitamin D is an antioxidant and up-regulates the production
of several neurotrophic factors that promote the survival,
development and function of neurons [63,64]. Prior studies have
demonstrated that low vitamin D level is associated with white
matter abnormalities in the brain including large vessel infarcts
[65], cerebrovascular accidents [66], and fatal stroke in coronary
angiography patients [67]. Vitamin D stimulates phagocytic
        
characteristic of Alzheimer’s disease that triggers neuronal
degeneration of cerebral cortex [68]. The exact mechanism by
        
neuropsychiatric conditions is not clear. Several studies have
associated low vitamin D level to increased risk of cerebrovascular
pathology and dementia via increased vascular hypertension [69],
hyperglycemic damage from diabetes [70], altered endothelial
function, plaque deposition via atherosclerosis [71], and
cerebrovascular diseases [72]. One longitudinal study indicated
that consuming more than 800 IU of vitamin D per day resulted
     
years of follow up [73]. Hence, majority of studies highlight that
neurological conditions including dementia, cognitive disorders
and Alzheimer’s disease in older adults [73,74].
Vitamin D supplementation not only can prevent neurological
disorders such as dementia but also psychiatric conditions
including depression [73]. Prior studies indicate that low level
of vitamin D is associated with the presence and severity of
depressive symptoms and thus may pose an underlying biological
vulnerability for depression [75]. A population study conducted
among middle to older aged community dwelling European
men, reported that lower level of vitamin D is associated with
depression [76]. Similarly, another population based study
conducted in the United States, indicated that low vitamin D levels
are associated with depressive symptoms, especially in persons
with a history of depression [37]. Therefore, among older adults,
but also cognitive impairment and other comorbidities [77,78].
Chronic diseases
   
factors, increased distance from equator, shorter days related to
non-summer seasons, indoor lifestyle, darkly pigmented skin,
institutionalized/housebound, sunscreens, cover-up clothing, air
pollution, smoking, obesity, physical inactivity including chronic
diseases (renal disease, liver disease, malabsorption syndromes)
and drugs (glucocorticoids, immunosuppressive agents) [79].
latitudes and these individuals are often predisposed to various
chronic diseases including hypertension, type 1 diabetes mellitus,
autoimmune diseases, multiple sclerosis and chronic depression
[80]. Poor cardiovascular health including systemic hypertension,
left ventricular hypertrophy, atherosclerosis, adverse cardiac
events, cardio-metabolic conditions including metabolic
syndrome and type 2 diabetes mellitus is also associated with
low vitamin D level [79]. In the context of cardiovascular health,
       
up-regulates the renin-angiotensin-aldosterone system and
predisposes to arterial hypertension, smooth muscle hypertrophy
and chronic heart failure [81].
Two major studies associating low vitamin D level and
cardiovascular diseases are well documented. The Whitehall
study conducted a 13-year follow up of approximately 5409
older adults and reported that higher concentration of vitamin
D was inversely and linearly correlated with both vascular and
nonvascular disease mortality and that doubling of serum vitamin
  
mortality rates [82]. Similarly, the Copenhagen city heart study
examined approximately 10,170 Danish adults in 1981-1983 for
baseline cardiovascular risk factors and diseases and during a 29
year longitudinal follow up indicated that lower vitamin D level
was associated with a 64% higher risk of myocardial infarction,
57% higher risk of premature mortality and 81% higher risk of
         
        
and is associated with poor health-related quality of life [84].
        
with chronic kidney disease and dialysis patients [85,86]. Low
level of Vitamin D causes an increase in serum parathyroid
hormone (PTH) levels causing primary hyperparathyroidism
which in turn is associated with symptoms of depressive disorder
[87]. Therefore, studies indicate that low level of vitamin D is
associated with chronic diseases and depression.
Musculoskeletal disorders
Musculoskeletal disorders associated with low levels of vitamin
D include bone pain, muscle weakness, and low bone mineral
density which typically manifests as osteomalacia in adults [88].
Vitamin D level below 40 nmol/L, is common in North America and
predisposes individuals to musculoskeletal disorders, poor bone
and muscle health [89]. One Polish study reported that vitamin D
associated with adverse health consequences and can exacerbate
osteopenia, osteoporosis and fractures in adults [91].
        
associated with depression and anxiety [92]. Severe vitamin D
       
weakness and pain often noted in type 2 diabetic patients with
symptomatic relief after vitamin D replacement [76]. Therefore,
        
Citation: Sarkar S (2017) Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy. Int Phys Med Rehab J 1(4): 00021. DOI:
Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy 5/10
©2017 Sarkar
       
provides a simple resolution of symptoms from musculoskeletal
Treatment Recommendations
Light therapy
Bright Light Therapy (BLT) also known as phototherapy
        
        
mornings [94]. Light boxes are available for purchase and emit
full spectrum bright light similar in composition to sunlight that
exerts effect on chronobiology and autonomic nervous systems
   
and require 20-60 minutes of visual exposure to 10,000 lux of
    
[95,96]. Bright light is safe with minimal side-effects that include
eyestrain, headache, irritability, sleep disturbances and age-
related macular degeneration [97].
Light therapy-induced improvement to corrections of altered
circadian rhythm and serotonin neurotransmission during
depression with a seasonal pattern is also reported [98]. Light
therapy can be used alone or in conjunction with antidepressants
[99]. Prior studies indicate that when depressed, patients
have demonstrated a clinically effective response to bright
environmental light and light therapy administered daily for at
least several weeks [100-102]. Therefore bright light therapy is an
important substitute to sunlight in the management of depression
with a seasonal pattern.
Antidepressant treatment
Bupropion (Wellbutrin), a second generation, serotonin
reuptake inhibitor, antidepressant, available in an extended release
(XR) formulation (150-300 mg/day), has been FDA approved
and is effective for the prevention and treatment of depression
with a seasonal pattern [103]. Buproprion is associated with
mild side-effects that include headaches, insomnia and nausea
[104]. Duloxetine, a serotonin norepinephrine reuptake inhibitor
(SNRI) has dual effect as an antidepressant that not only showed
a good treatment response in 80% of patients but also maintained
a remission rate in 76% of patients after 8 weeks of treatment
Antidepressants, including selective serotonin reuptake
inhibitors (SSRIs) such as Fluoxetine (Prozac) and Sertraline
(Zoloft) are often used in the treatment of depression with a
seasonal pattern [106]. Lamotrigine (mood stabilizer) is used
for augmentation of antidepressant medications and is clinically
effective after 4-8 weeks of treatment for depression with a
dopamine inhibitor, is used to reduce fatigue and excessive
sleepiness in winter season associated with the clinical condition
     
along with other pharmacological agents (beta blockers, mood
stabilizers, tryptophan, cyanocobalamine are often used in the
treatment of depression with a seasonal pattern [110].
Melatonin has an agonistic action on MT1/MT2 melatonergic
receptors, an antagonistic action at 5HT2c serotonergic receptor
and exerts an antidepressant and sleep enhancing effect [111].
Melatonin and its’ analogues are available over the counter
and is usually administered orally [112]. Low dose melatonin
is administered in the mornings to regulate the disrupted
circadian rhythm associated with winter depression especially in
geographical locations where sunlight exposure is minimal and
has proven effective in improving depression, sleep disturbances
and other health conditions [24].
Psychotherapy and Counseling
Cognitive behavioral factors including negative thoughts and
a progression from decreased activity enjoyment during fall to a
reduced activity frequency during winter is observed especially
among women suffering from depression with a seasonal pattern
[113]. In one study, six weeks of CBT during two 90 minute group
sessions per week was observed to be as effective as 30 minutes
of bright light therapy each morning [114]. CBT with or without
  
reduction in depression in winter compared to light therapy alone
Counselling program regarding dietary approaches targeted
towards limiting carbohydrates, increasing physical activity,
stress management, increasing social interactions and spending
        
that along with psychological counseling, consuming a diet rich
in proteins, fruits and vegetables along with other forms of
relaxation techniques including Transcendental Meditation (TM),
yoga, mindfulness, walking and exercise that alleviates stress
 
winter vacation to sunny locations can be a preventative strategy.
Therefore, CBT and counseling approaches that integrate novel
ways of thinking about sad mood and low energy level can provide
insight and emotional support to people experiencing depression
with a seasonal pattern.
Vitamin D therapy
Patients suffering from recurrent depression with a seasonal
        
investigating this association suggests that daily intake of 100,000
IU of vitamin D may improve the depressive symptoms and general
health [117]. Vitamin D therapy is available in three treatment
 
B (UVB) radiation, and vitamin D3 supplementation [118]. Since
this condition is prevalent in geographic locations where vitamin
D obtained from sunlight is little to none therefore vitamin
D3 supplementation is a simple and cost-effective strategy for
resolution of depressive symptoms during fall and winter seasons
        
not only in cold countries with long winters where sunlight
exposure is minimal but also in sunny countries like Asia and
Mediterranean regions where some people may not be exposed
Citation: Sarkar S (2017) Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy. Int Phys Med Rehab J 1(4): 00021. DOI:
Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy 6/10
©2017 Sarkar
to sunlight because of full skin covered clothing or an indoor-life
Algol et al. [46]. One clinical trial indicated that vitamin D as an
Therefore vitamin D supplementation is used as a preventative
and treatment strategy for depression with a seasonal pattern.
Practice Guidelines for Management of Vitamin D
Deficiency associated Depression
Prior studies have included practice guidelines [121-129].
These include
i. Establish a good therapeutic alliance with vitamin D
      
    
a caring, compassionate patient-provider relationship that is
trustworthy is the key to successful management.
ii. Obtain a detailed clinical history, conduct mental status
examination, perform thorough physical exam, and formulate
a differential diagnosis that is necessary to rule out an
      
with psychiatric comorbidities including depression.
iii. Administer validated screening instruments with excellent
psychometric properties (patient health questionnaire
(PHQ-9), Beck Depression Inventory (BDI) etc. to assess
clinical condition, severity of depressive symptoms and to
monitor progress.
iv. Obtain laboratory exams (CBC with differential, metabolic
panel, renal function test, liver function test, serum calcium,
phosphorus, parathyroid, alkaline phosphatase, vitamin
D level, etc.) and a urine drug screen to rule out substance
induced mood disorder. Low vitamin D level may be
associated with secondary hyperparathyroidism. Thus,
increased serum levels of parathyroid hormone, increased
total or bone alkaline phosphatase levels, low 24-hour urine
calcium levels, low serum calcium and/or phosphorus level
v. Clinical and laboratory exams can be used to rule out causes
        
 
      
nephrotic syndrome (decreased levels of vitamin D-binding
protein). Gastrointestinal causes such as malabsorption
     
disease, amyloidosis, celiac sprue, malabsorptive bariatric
surgery procedures) and hepatic causes such as severe liver
disease or failure (decreased 25-hydroxylase activity) may
        
underlying cause needs to be treated.
vi. Consider obtaining advanced radiological imaging to
visualize underlying anatomic abnormalities or pathological
conditions such as decreased bone mineral density
(osteopenia or osteoporosis), non-traumatic (fragility)
fracture or skeletal pseudo fracture that might suggest
as deemed necessary. An expert skilled in reviewing these
images and placing them in the appropriate clinical context
is often the best person to include as part of the treatment
vii. Obtain consultation with psychiatrists, psychologists,
internists, radiologists, orthopedics, neurologists, pain
management specialists, as part of the multi-disciplinary
treatment team when necessary. Establish diagnosis and
discuss the treatment plan/regimen with the patient.
viii. Pharmacotherapy with multi-target agents (serotonin,
norepinephrine, dopamine) like bupropion (NDRI) or
duloxetine (SNRI) that act on several neurochemical
pathways may be necessary to treat depression with seasonal
line agent for depression with seasonal pattern. Additionally,
    
D3 supplementation can be provided along with intake of
ix. After initiating pharmacotherapy, monitor for effectiveness,
focusing on functional improvements such as sleep, activity,
concentration, mood, and even employment status. If the
side-effects are intolerable or improvement is not observed,
consider increasing the dose or switching to a new class
of medication or add adjunct bright light therapy (BLT) in
         
        
seasonal pattern and antidepressants can be added as an
adjunct therapy.
x. Advise contraception and provide family planning counseling
for women of childbearing age as these pharmacologic agents
could have teratogenic potential.
xi. Cognitive behavioral psychotherapy (CBT) when used in
combination with pharmacotherapy for depression with a
seasonal pattern can be effective and have a better resolution
of depressive symptoms.
xii. Self-management strategies (yoga, mindfulness, self-physical
therapy, meditation) complementary and alternative
medicine (CAM) modalities (medical massage) are often
pooled with mainstream therapies, a practice referred to as
for the prevention of recurrence or to address treatment-
resistant/refractory patients suffering from depression with
seasonal pattern.
Low level of vitamin D is associated with depression with a
seasonal pattern. It is prevalent in countries far away from the
is also observed in middle-eastern and other countries located in
the tropical zone that receive abundant sunshine primarily due to
lifestyle factors such as indoor living and wearing fully covered
clothing causing lack of exposure of skin to sunlight. Risk factors
include advanced age, female gender, pigmented skin, increased
body mass index, indoor lifestyle, physical inactivity, sunscreen,
Citation: Sarkar S (2017) Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy. Int Phys Med Rehab J 1(4): 00021. DOI:
Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy 7/10
©2017 Sarkar
covered clothing, geographical location etc. Exact mechanism
linking the association between low vitamin D level and depression
is not clear. Prior studies have indicated that reduced exposure
to sunlight is associated with decreased serotonin activity, an
increased production of melatonin by melanocytes in the skin,
changes in circadian rhythm, and low vitamin D level in the
body. Treatment strategies include light therapy, antidepressant
medications, melatonin, psychotherapy/ counseling, and
vitamin D therapy. Among all the treatment options, vitamin D
 
and therapeutic strategy for the management of depression with a
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Vitamin D for Depression with a Seasonal Pattern: an Effective Treatment Strategy 9/10
©2017 Sarkar
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... In fact, it is well known that the prevalence of major depressive disorder and seasonal affective disorder has been relatively high in countries with a northern latitude, where there is an increased risk for vitamin D deficiency. In contrast, decreased vitamin D levels were also observed in southern countries such as Brazil, India, and Australia, as well as countries in Asia and the Middle East, but not all of those regions have a high prevalence of depressive disorders [28]. However, research reports on this topic in various regions are still insufficient; therefore, based on the results of this study in Korea, additional studies in various regions and further studies on multinational backgrounds will be needed in the future. ...
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Vitamin D deficiency is considered a major public health problem worldwide and has been reported as having an association with depression. However, studies on the association between vitamin D deficiency and depressive symptoms in secondary amenorrhea (SA) patients are still scarce. This study examined the relationship between serum 25-hydroxyvitamin D (25(OH)D) levels and depressive symptoms among Korean women with SA. In this cross-sectional observational study, 78 patients with SA were initially recruited. Clinical and biochemical parameters, including serum 25(OH)D level, were measured. Data from 63 SA patients who met the study inclusion criteria and completed psychiatric assessments were finally analyzed. We analyzed their association with depression using a hierarchical regression model. The average serum 25(OH)D level was 34.40 ± 24.02 ng/mL, and 41.3% of the women with SA were vitamin D-deficient (<20 ng/mL). The total score of the Korean version of the Hamilton Depression Rating Scale (K-HDRS) was negatively related to serum 25(OH)D levels, free testosterone, and serum anti-Müllerian hormone (AMH) after adjusting for age and BMI (r = −0.450, p < 0.001; r = −0.258, p = 0.045; and r = −0.339, p = 0.006, respectively). Serum 25(OH)D levels and AMH levels were the most powerful predictors of depressive severity when using the K-HDRS in SA patients (β = −0.39, p < 0.005; β = −0.42, p < 0.005, respectively). This study showed that low serum 25(OH)D levels were associated with the severity of depressive symptoms in SA patients. This observation suggests that the evaluation of vitamin D deficiency for the risk of depression may be necessary in patients with SA.
... The issue concerning how much exposure is too much is a very delicate matter and a hard one to concretely define and achieve. A balanced beach practice is a complex definition that depends mainly on time of exposure, latitude, sun intensity and skin type [6]. ...
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—In order to create a type of body art that relies on sun tanning, it’s essential to create a debate on what is a balanced UV exposure. While there are problems between lack of and excessive sun bathing, other threats to the well-being of the individual lay with the beaches’ biosphere, which may endanger the user as well. Acknowledging these circumstances is a necessary step in the process of making the perfect body suit for this kind of practice. As part of a good design process, it takes on the many challenges the intensive beach practitioner faces and incorporates them in the manufacturing process, looking for the required adaptions according to multiple factors.
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Vitamin D deficiency (<20 ng/mL) and insufficiency (20-29 ng/mL) are common among patients with chronic kidney disease (CKD) or undergoing dialysis. In addition to nutritional and sunlight exposure deficits, factors that affect vitamin D deficiency include race, sex, age, obesity and impaired vitamin D synthesis and metabolism. Serum 1,25(OH)2D levels also decrease progressively because of 25(OH)D deficiency, together with impaired availability of 25(OH)D by renal proximal tubular cells, high fibroblast growth factor (FGF)-23 and decreased functional renal tissue. As in the general population, this condition is associated with increased morbidity and poor outcomes. Together with the progressive decline of serum calcitriol, vitamin D deficiency leads to secondary hyperparathyroidism (SHPT) and its complications, tertiary hyperparathyroidism and hypercalcemia, which require surgical parathyroidectomy or calcimimetics. Kidney Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease Improving Global Outcomes (KDIGO) experts have recognized that vitamin D insufficiency and deficiency should be avoided in CKD and dialysis patients by using supplementation to prevent SHPT. Many vitamin D supplementation regimens using either ergocalciferol or cholecalciferol daily, weekly or monthly have been reported. The benefit of native vitamin D supplementation remains debatable because observational studies suggest that vitamin D receptor activator (VDRA) use is associated with better outcomes and it is more efficient for decreasing the serum parathormone (PTH) levels. Vitamin D has pleiotropic effects on the immune, cardiovascular and neurological systems and on antineoplastic activity. Extra-renal organs possess the enzymatic capacity to convert 25(OH)D to 1,25(OH)2D. Despite many unanswered questions, much data support vitamin D use in renal patients. This article emphasizes the role of native vitamin D replacement during all-phases of CKD together with VDRA when SHPT persists.
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Background. Hypovitaminosis D, a common condition in older adults, is associated with brain changes and dementia. Given the fast growing contribution of literature in this research field, clear guidance is needed for clinicians and researchers. Methods. International experts met at the invitational summit on "Vitamin D and cognition in older adults" in Boston, MA, July 2013. Based upon literature and expert opinion, the task force focused on key questions on the role of vitamin D in Alzheimer disease and related disorders. Each question was discussed and voted using a Delphi-like approach. Results. Experts reached agreement that hypovitaminosis D increases the risk of cognitive decline and dementia in older adults, may alter the clinical presentation as a consequence of related comorbidities, but should not be used thus far as a diagnostic or prognostic biomarker of Alzheimer disease due to lack of specificity and insufficient evidence. Hypovitaminosis D should be screened in this population because of its high prevalence and supplemented, if necessary, but this advice was not specific to cognition. Conclusions. The task force agreed on 5 overarching principles related to vitamin D and cognition in older adults.
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Seasonal affective disorder (SAD) is defined as a subtype of mood disorders in DSM 5, and it is characterized by a seasonal onset. SAD is proposed to be related to the seasonal changes in naturally occurring light, and the use of bright light therapy for depressive symptoms has been shown to reduce them in placebo controlled trials. Cognitive behavioral therapy has also been demonstrated to be effective in SAD. This review article aims to focus on the psychopharmacological treatment options for SAD. According to clinical trial results, first line treatment options seem to be sertraline and fluoxetine, and are well tolerated by the patients. There is some evidence that other antidepressants (e.g. bupropion) might be effective as well. Although clinical trials have shown that some of these antidepressants may be of benefit, a recent review has concluded that there is not enough evidence to support the use of any of these agents for the treatment of SAD yet. Moreover, more studies are still needed to evaluate the effectiveness of other treatment options, e.g., propranolol, melatonin, hypericum, etc. In addition to the above proposed treatments, patients with seasonal depressive symptoms should thoroughly be evaluated for any cues of bipolarity, and their treatment should be planned accordingly.
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Background: The association between low levels of vitamin D and the occurrence of chronic widespread pain (CWP) remains unclear. The aim of our analysis was to determine the relationship between low vitamin D levels and the risk of developing CWP in a population sample of middle age and elderly men. Methods: Three thousand three hundred sixty nine men aged 40-79 were recruited from 8 European centres for a longitudinal study of male ageing, the European Male Ageing Study. At baseline participants underwent assessment of lifestyle, health factors, physical characteristics and gave a fasting blood sample. The occurrence of pain was assessed at baseline and follow up (a mean of 4.3 years later) by shading painful sites on a body manikin. The presence of CWP was determined using the ACR criteria for fibromyalgia. Serum 25-hydroxyvitamin D (25-(OH) D) was assessed by radioimmunoassay. Logistic regression was used to determine the relationship between baseline vitamin D levels and the new occurrence of CWP. Results: Two thousand three hundred thirteen men, mean age 58.8 years (SD = 10.6), had complete pain and vitamin data available and contributed to this analysis. 151 (6.5 %) developed new CWP at follow up and 577 (24.9 %) were pain free at both time points, the comparator group. After adjustment for age and centre, physical performance and number of comorbidities, compared to those in upper quintile of 25-(OH) D ( ≥36.3 ng/mL), those in the lowest quintile (<15.6 ng/mL) were more likely to develop CWP (Odds Ratio [OR] = 1.93; 95 % CI = 1.0-3.6). Further adjustment for BMI (OR = 1.67; 95 % CI = 0.93-3.02) or depression (OR = 1.77; 95 % CI = 0.98-3.21), however rendered the association non-significant. Conclusions: Low vitamin D is linked with the new occurrence of CWP, although this may be explained by underlying adverse health factors, particularly obesity and depression.
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Seasonal affective disorder or SAD is a recurrent major depressive disorder with a seasonal pattern usually beginning in fall and continuing into winter months. A subsyndromal type of SAD, or S-SAD, is commonly known as “winter blues.” Less often, SAD causes depression in the spring or early summer. Symptoms center on sad mood and low energy. Those most at risk are female, are younger, live far from the equator, and have family histories of depression, bipolar disorder, or SAD. Screening instruments include the Seasonal Pattern Assessment Questionnaire (SPAQ). Typical treatment includes antidepressant medications, light therapy, Vitamin D, and counselling. This paper provides an overview of SAD.
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Background: Vitamin D may decrease depression symptoms through its beneficial effects on neurotransmitters, metabolic profiles, biomarkers of inflammation, and oxidative stress. Objective: This study was designed to assess whether vitamin D supplementation can reduce symptoms of depression, metabolic profiles, serum high-sensitivity C-reactive protein (hs-CRP), and biomarkers of oxidative stress in patients with major depressive disorder (MDD). Methods: This randomized, double-blind, placebo-controlled clinical trial was performed in 40 patients between 18 and 65 y of age with a diagnosis of MDD based on criteria from the Diagnostic and Statistical Manual of Mental Disorders. Patients were randomly assigned to receive either a single capsule of 50 kIU vitamin D/wk (n = 20) or placebo (n = 20) for 8 wk. Fasting blood samples were taken at baseline and postintervention to quantify relevant variables. The primary [Beck Depression Inventory (BDI), which examines depressive symptoms] and secondary (glucose homeostasis variables, lipid profiles, hs-CRP, and biomarkers of oxidative stress) outcomes were assessed. Results: Baseline concentrations of mean serum 25-hydroxyvitamin D were significantly different between the 2 groups (9.2 ± 6.0 and 13.6 ± 7.9 μg/L in the placebo and control groups, respectively, P = 0.02). After 8 wk of intervention, changes in serum 25-hydroxyvitamin D concentrations were significantly greater in the vitamin D group (+20.4 μg/L) than in the placebo group (-0.9 μg/L, P < 0.001). A trend toward a greater decrease in the BDI was observed in the vitamin D group than in the placebo group (-8.0 and -3.3, respectively, P = 0.06). Changes in serum insulin (-3.6 compared with +2.9 μIU/mL, P = 0.02), estimated homeostasis model assessment of insulin resistance (-1.0 compared with +0.6, P = 0.01), estimated homeostasis model assessment of β cell function (-13.9 compared with +10.3, P = 0.03), plasma total antioxidant capacity (+63.1 compared with -23.4 mmol/L, P = 0.04), and glutathione (+170 compared with -213 μmol/L, P = 0.04) in the vitamin D group were significantly different from those in the placebo group. Conclusion: Overall, vitamin D supplementation of patients with MDD for 8 wk had beneficial effects on the BDI, indicators of glucose homeostasis, and oxidative stress. This trial was registered at as IRCT201412065623N29.
Vitamin D deficiency is now recognized as a pandemic. The major cause of vitamin D deficiency is the lack of appreciation that sun exposure in moderation is the major source of vitamin D for most humans. Very few foods naturally contain vitamin D, and foods that are fortified with vitamin D are often inadequate to satisfy either a child's or an adult's vitamin D requirement. Vitamin D deficiency causes rickets in children and will precipitate and exacerbate osteopenia, osteoporosis, and fractures in adults. Vitamin D deficiency has been associated with increased risk of common cancers, autoimmune diseases, hypertension, and infectious diseases. A circulating level of 25-hydroxyvitamin D of >75 nmol/L, or 30 ng/mL, is required to maximize vitamin D's beneficial effects for health. In the absence of adequate sun exposure, at least 800–1000 IU vitamin D3/d may be needed to achieve this in children and adults. Vitamin D2 may be equally effective for maintaining circulating concentrations of 25-hydroxyvitamin D when given in physiologic concentrations.
Background: Vitamin D deficiency is prevalent in India, a finding that is unexpected in a tropical country with abundant sunshine. Vitamin D deficiency during pregnancy has important implications for the newborn and infant. There are few data from India about the prevalence of hypovitaminosis D in pregnancy and in the newborn. Objective: Our aim was to determine the prevalence of osteomalacia and hypovitaminosis D in pregnancy and in cord blood and to correlate maternal 25-hydroxyvitamin D [25(OH)D] status with sun exposure, daily calcium intake (dietary plus supplemental), and intact parathyroid hormone (PTH) concentrations. Design: Serum calcium, inorganic phosphorus, 25(OH)D, heat-labile alkaline phosphatase, and PTH were studied in 207 urban and rural pregnant subjects at term. Alkaline phosphatase and 25(OH)D were measured in the cord blood of 117 newborns. Results: Mean maternal serum 25(OH)D was 14 ± 9.3 ng/mL, and cord blood 25(OH)D was 8.4 ± 5.7 ng/mL. PTH rose above the normal range when 25(OH)D was <22.5 ng/mL. Eighty-four percent of women (84.3% of urban and 83.6% of rural women) had 25(OH)D values below that cutoff. Fourteen percent of the subjects had elevated alkaline phosphatase (17% of urban and 7% of rural subjects). Calcium intake was uniformly low, although higher in urban (842 ± 459 mg/d) than in rural (549 ± 404 mg/d) subjects (P < 0.001). Maternal serum 25(OH)D correlated positively with cord blood 25(OH)D (r = 0.79, P < 0.001) and negatively with PTH (r = −0.35, P < 0.001). Conclusion: We observed a high prevalence of physiologically significant hypovitaminosis D among pregnant women and their newborns, the magnitude of which warrants public health intervention.
Reduced exposure to daytime sunlight and increased exposure to electrical lighting at night leads to late circadian and sleep timing [1-3]. We have previously shown that exposure to a natural summer 14 hr 40 min:9 hr 20 min light-dark cycle entrains the human circadian clock to solar time, such that the internal biological night begins near sunset and ends near sunrise [1]. Here we show that the beginning of the biological night and sleep occur earlier after a week's exposure to a natural winter 9 hr 20 min:14 hr 40 min light-dark cycle as compared to the modern electrical lighting environment. Further, we find that the human circadian clock is sensitive to seasonal changes in the natural light-dark cycle, showing an expansion of the biological night in winter compared to summer, akin to that seen in non-humans [4-8]. We also show that circadian and sleep timing occur earlier after spending a weekend camping in a summer 14 hr 39 min:9 hr 21 min natural light-dark cycle compared to a typical weekend in the modern environment. Weekend exposure to natural light was sufficient to achieve ∼69% of the shift in circadian timing we previously reported after a week's exposure to natural light [1]. These findings provide evidence that the human circadian clock adapts to seasonal changes in the natural light-dark cycle and is timed later in the modern environment in both winter and summer. Further, we demonstrate that earlier circadian timing can be rapidly achieved through natural light exposure during a weekend spent camping.
Beyond effects on bone health, vitamin D exerts effects on a variety of target organs, including the brain. The discussion herein presents the state of the art in research on the neurological role of vitamin D and clinical implications among older adults, including implications for dementia onset and progression. Some of the neurosteroid actions of vitamin D include regulation of calcium homeostasis, clearance of amyloid-β peptide, antioxidant and anti-inflammatory effects, and possible protection against the neurodegenerative mechanisms associated with Alzheimer's disease (AD). The correction of age-related hypovitaminosis D and cognitive decline has been reported by various cross-sectional and longitudinal studies reporting associations of lower vitamin D concentrations with brain changes and poorer cognition, specifically with respect to executive dysfunction. Epidemiological studies have consistently shown an association between inadequate dietary intake of vitamin D and cognitive disorders, including greater AD risk. Although there have not been any randomized placebo-controlled trials conducted to examine the effectiveness of vitamin D supplementation to prevent AD, several nonrandomized controlled studies have found that older adults experienced cognitive improvements after 1-15 months of vitamin D supplementation. Therefore, it appears crucial to maintain vitamin D concentrations at sufficiently high levels in order to slow, prevent, or improve neurocognitive decline.