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Seasonal Affective Disorder: A Chinese Medicine Approach

The DSM-5-TR (text revision 2022) defines Seasonal Affective Disorder (SAD) as a “major depressive disorder with seasonal pattern.” Although SAD doesn’t necessarily occur in individuals every year to the same severity, a biomedical diagnosis depends on the symptoms lasting for 4 – 5 months, for at least two consecutive years.  The average onset of Seasonal Affective Disorder is between 18 to 30 years old, and among those diagnosed it affects cis-female and AFAB (assigned female at birth)* persons disproportionately, representing 80% of those diagnosed. Seasonal Affective Disorder can co-manifest with other mental health concerns, such as bipolar, schizophrenia, and ADHD, as well as eating, anxiety, and panic disorders.

photo of sad woman looking out a rainy window

There are two main types of Seasonal Affective Disorder: winter and summer. Both types are associated with changes in melatonin and serotonin levels due to light exposure. Winter-type SAD is certainly more well-known: statistics suggest 5% of the US population suffer from this type, but the prevalence varies greatly based on geography, with up to 10% of northern state populations, and close to 0% in southern states.

For those in the northern hemisphere, winter symptoms tend to begin in November – December, with increased symptoms in January and February; summer symptoms will start in May – June. Symptoms associated with Seasonal Affective Disorder are related to changes in daylight hours, not the calendar, so the regular stress and emotions associated with holidays, changes in work or school schedules, and family visits are not the same as SAD. 

In both types of Seasonal Affective Disorder, some or all of the classic symptoms of depression will be seen, along with more winter or summer specific symptoms. General symptoms of depression seen in both types of SAD include the following: 

  • Consistently sad, anxious, or “numb” for at least 2 weeks
  • Feelings of hopelessness, pessimism, irritability, frustration, restlessness, guilt, worthlessness, or helplessness
  • Difficulty concentrating, remembering, or making decisions 
  • Changes in sleep or appetite
  • Unplanned weight changes
  • Poor energy or fatigue
  • Loss of interest or pleasure in activities
  • Physical aches or pains, including headaches, cramps, or digestive problems with no clear physical cause and not resolving with treatment
  • Thoughts of death or suicidality

Symptoms specific to winter SAD include: 

  • Excessive sleeping
  • Overeating, craving carbohydrates, weight gain
  • Social withdrawal

And for summer SAD, specific symptoms include:

  • Insomnia
  • Poor appetite, weight loss
  • Anxiety, restlessness, agitation
  • Violent or aggressive behavior

Evidence-based research into best treatments for Seasonal Affective Disorder is on-going, but the current protocol is a combination of mental health counseling and anti-depressants for either type of SAD, with the addition of two protocols for winter SAD: light therapy – including exposure to natural sunlight – and Vitamin D, to promote serotonin activity. As summer SAD is less prevalent it has not been researched to the same level as winter SAD, so there are currently no biomedical treatments specific to summer Seasonal Affective Disorder.

Chinese medicine concepts of Ultimate Yin and Ultimate Yang

When we examine the seasons from a Yin-Yang perspective, we know that winter aligns with Ultimate Yin, and summer aligns with Ultimate Yang; these are times of year when the respective Yin or Yang energies are at their most effulgent. Obviously, if people are already struggling with Yin or Yang issues, they are much more likely to get thrown off by the seasonal high points near the solstices. For example, someone with either a Yin Excess or Yang Deficient condition is more likely to experience depressive symptoms in the cold-wet weather of winter, when either of these states might become more pronounced. And of course, someone with a Yang Excess or Yin Deficient condition could have more pronounced depressive symptoms in the heat of summer.

The symptoms of Seasonal Affective Disorder from the biomedical model align well with this Yin-Yang diagnostic perspective, where insomnia, weight loss, restlessness or agitation, and violent or aggressive behavior are associated with summer SAD (the Yang Excess or Yin Deficient presentation), and excessive sleep, weight gain, fatigue, and social withdrawal are associated with winter SAD (the Yang Deficient or Yin Excess presentation). One could therefore make easy assumptions about treatment options, like prioritizing the use of moxa and warming herbs for winter Seasonal Affective Disorder and relying heavily on cooling foods and herbal formulas for summer SAD.

However, this view is unfortunately far too simplistic for the majority of clients that come to us in relatively affluent nations, where the Chinese medical understanding of Heat pathology has become far too commonplace. 

Bian Hua 變化– To Change and Transform

Heat pathology can easily arise from a diet rich in spices, oils, high temperature cooking (think deep fried foods), alcohol, sugars, and caffeine. Heat can also arise from a fast-paced lifestyle with excessive amounts of stimuli: visual, mental-emotional, and so on. If contemporary western diet and lifestyle factors aren’t the cause, Heat can also arise from external pathogens that are difficult to properly clear or naturally go into latency such as herpes, varicella, Lyme, and even COVID-19. Our planet is also over-heating due to climate change, driving up environmental temperatures to extreme levels that we are all being exposed to more regularly.

Looking back to Yin-Yang Theory, the concept of Bian Hua 變化 – change and transformation – is a natural part of life: nothing remains static when living organisms are involved. Therefore, any type of Heat that has entered the body will be subject to the principle of Bian Hua, and change or transform into something else. Whether acute and extreme, or chronic and more moderate, the presence of Heat pathology will directly impact the fluids, depleting supply until a secondary condition of Dryness results. And what we know of Yin and Yang – in their constant dance to balance each other – is that Dryness will eventually lead to the formation of pathological Yin (i.e., Dampness) as the body tries to mitigate damage to the fluids. This Dampness will obstruct the natural movements of Qi, creating stagnation that drives up internal friction and adds to any Heat, which will further dry out the body fluids and create Phlegm. So over time, a self-propelled, on-going cycle of Heat to Dryness to Damp-Phlegm to Stagnation will form. It is worthy to note that if the Stagnation is not cleared, the force required to move Qi and Blood will combine with Heat and eventually lead to internal Wind, but the presence of Wind is not generally associated with the symptoms of Seasonal Affective Disorder.

Therefore, due to diet, lifestyle, lingering pathogens, and/or environment, the common pathologies in Seasonal Affective Disorder are Heat, Dryness, Damp-Phlegm, and Stagnation (likely of both Qi and Blood), with varying degrees of pattern prevalence based on the type of SAD. In winter Seasonal Affective Disorder, the Qi Stagnation and Damp-Phlegm will likely be more pronounced, whereas Dryness and Heat would be the more dominant patterns in summer SAD.

How does this apply to the treatment of Seasonal Affective Disorder?

 

Keeping the combination of Heat, Dryness, Damp-Phlegm, and Stagnation in mind is important when designing a treatment plan, as relying on Yang warming herbs for a winter SAD condition could easily aggravate the underlying Heat, whereas using Yin moistening or strong Heat-clearing herbs for a summer SAD condition could easily aggravate Dampness and further contribute to Qi Stagnation. Harmonization is therefore the key to unwinding this condition.

Case Examples

Case 1: Cis-female, 39, Tucson, AZ

Summer Seasonal Affective Disorder diagnosis at age 36. Originally diagnosed with stress and IBS, then post-partum depression / PPD, and then SAD.

  • Onset at age 33, about 10 months after the birth of her first child. At onset, she was finishing a PhD thesis, working full-time in academia, and parenting.
  • She grew up in Portland, OR. She is of average – thin build.
  • Symptoms include insomnia and restlessness, quick temper, anxiety and difficulty concentrating, lack of interest in social engagements, digestive upsets (diarrhea with pain), and occasional debilitating fatigue with the digestive upsets.
  • Other symptoms include recalcitrant tension (neck, shoulders, hamstrings, etc.), daily sweet cravings; menses is occasionally delayed, but typically includes cramping for 2 – 3 days (managed with NSAIDs), darker color, and tiny clots.
  • She enjoys running (3 – 5 miles almost daily), cycling, and hiking, which she can do all year in the desert climate. Her diet includes coffee (2 – 3 cups a day), daily sweet treats / desserts, alcohol 2 – 4 times a week, supplements for iron and B Vitamins (recommended by the acupuncturist she saw for PPD), and she drinks 10 – 12 glasses of water per day – “Desert living, am I right?” she says.
  • Tongue is normal in color and coat overall, but the tip is bright red at the border with a scanty coat, and the body is slightly puffy.
  • Pulse is wiry in Liver and Large Intestine positions, empty in Stomach-Spleen position, and slightly thin on the left side.

On the surface, this client appears easy to treat: a simple case of Liver Qi Stagnation and Spleen Qi Deficiency (i.e., Liver invading Spleen) leading to a secondary and mild Blood Deficiency – Stasis, with Heat arising as a tertiary pattern from both Qi Stagnation and Blood Deficiency. Just pull out the Xiao Yao Wan and move on! In fact, she could likely feel much better using that treatment strategy for a couple months, but as the Qi Stagnation is coursed, the Blood nourished, and the Heat gently cleared, deep sinus congestion, post-nasal drip, and bowel disturbances will likely arise from the Dampness and Phlegm revealing themselves more clearly (note the wiry Large Intestine pulse).

Rather than blaming it on ‘new’ environmental allergies or food sensitivities, it is important to see that the Dampness was already present, well hidden by both desert climate and internal Heat. Once the Dampness is addressed, the Dryness and/or Heat that are being masked by pathological Yin will dominate the presentation, and the root cause of the on-going Heat will likely become more dramatic. Is it the coffee that triggers symptoms? Is it being outside in the sun too much? Perhaps she might experience a sudden and severe relapse of a latent Heat pathogen during the course of treatment? And if she stops exercising (i.e., coursing the Qi) for a few days, does the Stagnation get significantly worse? Regardless, if you keep in mind the combination of Heat, Dryness, Damp-Phlegm, and Stagnation, treating all four aspects of the condition simultaneously, with mindful attention to diet and lifestyle recommendations, all four patterns will eventually resolve.

 

Case 2: Gender-queer/AFAB, 45, living in Concord, NH

Diagnosed with winter SAD at age 20.

  • Symptoms began freshman year of college in New England and were initially associated with being far from home and stress. Full evaluation and diagnosis came during junior year of college. 
  • They grew up in Denver, CO, and are of heavier build.
  • Symptoms include diminished emotions / feeling “numb,” sadness and self-worth issues, difficulty concentrating and making decisions, extreme fatigue, sleeping 9 – 10 hours and wanting more, difficulty motivating, and mild headaches with “fuzzy” or “foggy” head sensation. Before diagnosis and treatment, they also experienced constant sweet cravings, weight gain, and suicidal ideation.
  • Other symptoms include year-round allergies with white / clear discharge, food sensitivities (dairy and gluten – started in college), constipation (slow, not dry stools), occasional dry mouth, abdominal bloating at ovulation and pre-menses, delayed menses with sacrum pain (no cramps or clots), eye strain and tension headaches with excessive computer use, and shoulder-neck-jaw tension.
  • They enjoy walking, yoga / meditation, and swimming, and typically do one of these for 20 – 60 minutes daily. They eat meat 2 – 4 days per week (chicken or beef), with daily green tea, sweet treats / desserts a couple times a week, alcohol 2 – 4 times per month, and seltzer / carbonation when stools aren’t moving.
  • Tongue is puffy and pale, with a slightly dry coat.
  • Pulse is slippery-full on the right side, and thin-weak on the left.
  • Current treatment includes daily light therapy and weekly counseling sessions, along with allergy medication (cetirizine) and Vitamin D.

Onset at 18 was clearly triggered by the move from Denver to New England, which is both more northern latitude and a damper climate. Therefore, Dampness could have been present before the move, but balanced out by the arid environment of Colorado. The dry mouth, slightly dry coat on the tongue, occasional eye strain, and thin pulse are potential indicators of Dryness or fluid insufficiency; but dry mouth is also a common side effect of their allergy medication, and a thinner pulse and occasional eye strain could be post-menstrual and/or indicate a mild Blood deficiency resulting from the more obvious Spleen-Stomach deficiency.

On the surface, this case again seems clear: tonify Spleen-Stomach Qi and resolve Dampness / Phlegm, while secondarily coursing any Qi Stagnation caused by Damp obstructions and nourishing any Blood Deficiency caused by Spleen/Stomach insufficiency (which could also be contributing to the Qi Stagnation). One might consider Liu Jun Zi Wan or a combination of Si Jun Zi Wan and Er Chan Wan, perhaps incorporating Ba Zhen Wan or Si Wu Wan if Blood Deficiency is more obvious in the post-menstrual phase.  If the diagnosis is correct, their overall diet isn’t Damp-promoting, and they are staying warm enough to preserve Qi, many symptoms will resolve relatively quickly.

But keeping in mind the Heat – Dryness – Dampness / Phlegm – Stagnation combination from the co-factors of modern living, there is likely an underlying Heat hiding somewhere. Clearing away the Dampness will surely expose the Heat; from clinical expertise, the sinus congestion changing from white / clear discharge to sticky and yellow is often the first sign of Heat rising to the surface. With the history of year-round allergies inflaming the sinus passages, perhaps consider Cang Er Zi Wan or Pe Min Kan Wan even before the congestion turns yellow and sticky. I often find that chronic sinus congestion (of any mucous color) doesn’t transform until Heat in the sinuses is cleared away, so I invite you to begin that process as early as possible.

With clients who present with extensive Dampness, health history is not always presented in a linear, easily comprehensible fashion. And as Dampness is cleared away, root patterns will always reveal themselves. Even more importantly, the client themselves becomes better at seeing the past to help identify the true onset of the condition; this will obviously help with determining how to most effectively target the root. When Dampness is a dominant pattern, always assume the condition will take longer to treat.

Conclusion

Clients with Seasonal Affective Disorder do not often fit a simplistic Yang Deficient or Yin Excess presentation for a winter SAD, or the Yin Deficient or Yang Excess for summer SAD. When this happens, consider the concepts of diet, lifestyle, lingering pathogens, and climate change as potential causative factors, and look for signs of the Heat – Dryness – Damp-Phlegm – Stagnation cycle at play.

When resolving presenting patterns, it is common that the causative or root patterns of Seasonal Affective Disorder will become clear. Don’t automatically assume that the treatment principles are incorrect for what you’ve been working with, or that the condition is worsening. Keep in mind that any Heat underlying a winter SAD condition will rise to the surface once the Stagnation and Dampness have started to clear, and that summer SAD conditions will have some Dampness and Qi Stagnation locking in the Heat and Dryness. Just ‘go easy’ on treatment modalities to ensure that balance is maintained as much as possible while encouraging healing. It is often enough to simply harmonize Fluids and course Qi to start resolving symptoms, with a watchful eye toward the Heat that is likely hiding underneath it all.

* Author’s Note: In the research articles and medical websites consulted for this article, diagnosed populations were consistently referred to by sex (ie, male v. female), with no data regarding intersex populations or gender distinction. Therefore, this article assumes that any data regarding ‘females’ would include both cis-women and AFAB (assigned female at birth) persons.

About the Author

C. ‘Captain’ Lumenello, DAc (they / them) is the author of Gender & Sexuality in Chinese Medicine (Singing Dragon UK, 2020), and a contributing author in Ethics for Acupuncturists (Singing Dragon UK, 2024). In private practice since 2005, Dr. Lumenello is also a Qigong and Feng Shui Master that specializes in the treatment of trauma / PTSD recovery and auto-immune conditions. Dr. C moved to the Green Mountains of rural Vermont in 2016, where they maintain a private practice, serve on the Vermont Acupuncture Association board (currently as President), and continue to mentor and lecture nationwide on topics related to trauma, LGBTQ+ concerns, and oppression. You can find out more at CatherineLumenello.com

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