Seasonal Affective Disorder: Causes, Symptoms, and Treatment

Purpose Statement 

Seasonal Affective Disorder (SAD) negatively impacts the lives of millions of people in the US and around the world. The symptoms that occur with SAD show consistency with others that occur with other types of depression hence making it challenging for medical practitioners to make a correct diagnosis. Although symptoms like mood fluctuations are mostly exhibited during winter months, some may occur in summer or spring (Leahy, 2017). In the winter months, patients exhibit symptoms such as an increased craving for carbohydrate foods, weight gain, excessive sleeping and fatigue, and an above-normal appetite. These are the symptoms that distinct SAD from other types of depression. Diagnosis for SAD can be made from an observed seasonal onset of symptoms over two or more seasons. 

Nursing Practitioners have a role in making a correct diagnosis of SAD and making recommendations for controlling the symptoms. Correct identification of symptoms determines the control techniques and outcomes of the treatment process. Hence, there is a need to equip nursing practitioners with sufficient knowledge on SAD including its symptoms and management. The fact that most SAD cases are brushed aside as winter blues adds a claim to the need for the correct diagnosis for health improvement in the general population. The disruptive symptoms of SAD require an evidence-based approach that is seemingly lacking or largely ignored among nursing practitioners owing to the high number of cases that remain untreated. Furthermore, SAD is known to have an onset in people between 20 to 30 years, hence focus education on people within this age bracket will help to improve diagnoses and outcomes. Furthermore, populations in the northern latitudes in areas such as Alaska have a prevalence of up to 10% compared to the national average of 5% (Kurlansik & Ibay, 2013). Therefore, this paper aims to provide education to people living in the northern latitudes on methods of identifying SAD symptoms in this populations and make recommendations for healthy lifestyle interventions. 

Literature Review 

Symptoms of SAD are attributed to biological and mood disturbances (Kurlansik & Ibay, 2013). Advance or delay of the circadian phase is the leading cause of SAD although other biological factors such as genetic variation which lead to poor circadian rhythms have been cited (Kurlansik & Ibay, 2013). Sensitivity to light in the retinal area is also a factor. Psychological factors relating to SAD may include stress vulnerability for the affected person and the period for diagnosis. Although symptoms tend to be consistent with other forms of depression, a seasonal or recurrence pattern of depression is the first sign of SAD. Remission of depression symptoms in the spring or summer months is another indicator of SAD (Leahy, 2017). Living in the northern latitudes is a risk factor hence latitudinal location is also considered in the diagnosis. Evidence shows that the three main treatments used on patients, light therapy, cognitive behavior therapy and pharmacotherapy (Kurlansik & Ibay, 2013), all relieve the symptoms although no single treatment or any combination has been found to be superior to the other. Treatment methods thus rely on patient preferences and reaction. 

The American Psychiatric Association distinguishes SAD from normal fatigue and unwillingness to work under the cold weather by categorizing as a major psychological disorder (Tish, 2014). Early diagnosis is cited as key in developing a plan for management of SAD. Activities such as sports, nature walks, and sun basking are thought to relieve symptoms. Abstinence from drugs and alcohol also helps to avoid escalation of symptoms. Gupta, Sharma, Garg, Singh and Mondal found that people affected by SAD had 5% more SERT, a serotonin neurotransmitter, than normal people. These high SERT level indicate a problem with mood control due to imbalances in the transportation of serotonin. Overproduction of melatonin, a hormone responsible for sleepiness during dark hours, also accounts for symptoms exhibited by patients. Increased levels of melatonin coupled with decreased serotonin levels in the body impacts on the circadian rhythms. People with SAD have difficulty in adjusting to these light-dark changes during the winter months hence the SAD symptoms. More people suffer from SAD in the Nothern latitudes than any other areas due to severe winters that affects light and dark rhythms. 

Although there exists a significant literature gap on how the intake of vitamin D on a daily basis during the winter months can help in suppressing the SAD symptoms, available findings indicate that low levels of vitamin D are associated with SAD (Melrose, 2015). Little or lack of exposure to sunlight means that the patient’s body is unable to produce efficient levels of vitamin D. Researchers do not sufficiently understand the link between vitamin D and serotonin, but deficiency is tied to clinically significant symptoms of SAD (Melrose, 2015). The existing link between vitamin D and serotonin impacts on the understanding of the condition and the need for further research. However, the existing knowledge on vitamin D deficiency and insufficiency in the body resulting in depression symptoms points to the efficiency of the intake of vitamin D in preventing SAD symptoms. 

Rohan et al., (2015) posited that cognitive behavioral therapy needs serious consideration even with the current statistics pointing to the success of light therapy. Daily light therapy is recommended for SAD patients from the appearance of the first symptoms until remission in the summer. However, the problem lies with a significant of patients whose symptoms do not remit even in the summer. This anomaly warrants an investigation into an alternative method that can be used to achieve positive outcomes in this group of patients. Clinical trials on the effectiveness of CBT in comparison with light therapy did not indicate any significant differences between the two methods (Rohan et al., 2015). The trials majored in regions with very little sunlight during the winter months with some receiving as little as ten hours of sunlight in a day. The severity of depression for both methods reduced within six weeks of therapy, although none of the two methods had a quicker succession rate. The fact that remission status did not differ for these methods shows consistency in results with earlier studies (Kurlansik & Ibay, 2013). These findings show that both CBT and light therapy are viable treatment methods for SAD patients. However, there is a need for further improvements in these methods to achieve high remission status in patients. Also, consideration of CBT as a direct alternative for light therapy is necessary. 

Previous studies have failed to effectively link serotonin levels in the body with SAD although low levels of serotonin are associated with SAD (Melrose, 2015). Serotonin is s neurotransmitter associated with important psychological and activity or in the body. Serotonin is known to control mood, sleep, emotions and appetite (Gupta, Sharma, Garg, Singh & Mondal, 2013). Thus disturbances in the body serotonergic systems are associated with disorders in moods. Furthermore, serotonin plays a crucial role in the cardiovascular, renal, and gastrointestinal systems (Gupta, Sharma, Garg, Singh & Mondal, 2013). However, the main interest of this neurotransmitter, in this case, is its activity in the brain where disturbances in its synthesis, uptake and transport results in various psychological problems. Low levels of serotonin in the brain hypothalamus region during winter months perfectly explains the caving for carbohydrate foods (Gupta, Sharma, Garg, Singh & Mondal, 2013). This is because this region is responsible for feeding regulation in humans and animals. The highest levels were found in the summer months of April and June. Fluctuations in diet cannot wholly explain the differences in serotonin levels in humans. However, the highest levels of serotonin in the summer months are responsible for remission of symptoms (Gupta, Sharma, Garg, Singh & Mondal, 2013). Hence, the success of light therapy in control of symptoms since it increases the light period thus increasing levels of serotonin. 

Light therapy is the most extensively studied and least elusive methods of treating SAD in adults with positive outcomes in over 70% of patients (Knapen, Van de Werken, Gordijn & Meesters, 2014). However, the length of the period required to achieve these outcomes differs, ranging from one week to six weeks of daily light therapy. Hence, an investigation into the reasons for these variations in timelines revealed various underlying factors Knapen, Van de Werken, Gordijn & Meesters, 2014). The role that patient expectation plays in response to light therapy is a significant factor in this therapy. Patient expectations lead to a greater response to light therapy in men than in women. Women have a greater response to light therapy due to higher expectations. This finding underlines the psychological role that attitude plays in determining treatment outcomes. 

Further research findings show that internet searches on mood disorders peak during winter and are lowest in the summer (Anglin, Samaan, Walter & McDonald, 2013). Such findings relate to the seasonal nature of affective disorders in the days of low sunlight. Previous research shows that environmental factors influence seasonal affective disorders whereas changes in daylight hours affect the circadian system leading to psychological irregularities in the body. Intense sunlight triggers absorption of vitamin D while low levels of sunlight result in vitamin deficiency. Furthermore, considering environmental factors, absorption of omega-3 is highest in the summer and lowest in winter (Anglin, Samaan, Walter & McDonald, 2013). Considering that omega-3 deficiency is associated with depression, the peaks and troughs in depression during winter and summer respectively could also be explained using this occurrence. Another contributor to the seasonality pattern of mental health is the activities carried out during the two extreme period, where the summer allows for outdoor activities and exercise which improves mental health and winters have most patients locked indoors where chances of negative psychological effects are high. Although environmental factors cannot independently account for the seasonal pattern of affective disorders, they form the basis for further research on the topic. 

The suitability of vitamin D supplements in treating SAD is not fully established (Spedding, 2014). Biological flaws in studies to establish the efficacy of vitamin D is partly responsible for this uncertainty. Although the relationship between vitamin D deficiency and depression has been known for centuries, effective use of supplements to treat depression such as the one caused by SAD con tunes to elude researchers (Spedding, 2014). Endocrine, pancrine and autocrine systems are influenced by vitamin D receptors hence impacting on the psychological systems (Spedding, 2014). Interestingly, vitamin D deficiency has been found to cause an increase of up to 14% in cases of depression. A review of controlled trials on the efficiency of vitamin D supplements in treating depression revealed that the supplements have therapeutic value (Spedding, 2014). Boosting the levels of vitamin D in the body has the effect of reducing depression, hence their suitability for treating SAD. 

Prevalence levels of SAD at high latitudes reaches up to 10% of the general population (Frandsen, Pareek, Hansen & Nielsen, 2014). Latitudes above 37N are high and have the largest portion of the population with deficiencies in vitamin D. The distribution of vitamin D receptors in the brain points to it being a neurosteroid hence its involvement in the psychological wellbeing of individuals. Latitudes above 37N are high and have the largest portion of the population with deficiencies in vitamin D. Several studies on the effect of supplements have produced varied results. Studies in small and large populations have revealed that high doses of vitamin D to people living in high latitudes produced positive results (Frandsen, Pareek, Hansen & Nielsen, 2014). However, low doses of the supplement given to large populations did not have a positive effect. Hence, the uncertainty continues to rage on the benefits of supplements and their dosages to SAD patients. 

Alternatively, prevalence levels are four times as higher in women than in men (Kurlansik & Ibay, 2013). This relation is however not fully studied and the causes for the high prevalence in the female sex established. Susceptibility to the condition increases moving northwards, with only 1% of the population in Florida experiencing SAD while 9% of the population in Alaska experiences the condition (Kurlansik & Ibay, 2013). This is due to the effect of reduced sunlight while moving towards the northern latitudes. However, these statistics are for the reported and diagnosed cases of SAD. Still millions of people fail to seek treatment for the condition by associating it with winter blues. Hence, there is a high likelihood of many people living with SAD and remaining untreated leading dysfunctional lifestyles. 

Nurse Practitioner Role 

Mental health is a thorny issue in the US, with over forty million people affected annually (Theophilos, Green, & Cashin, 2015). Mental health issue also poses challenges to the WHO with the declaration that mental health is vital for the overall health of the population. Two main factors compound the mental health problem in the US; people who suffer in silence and are unwilling to seek professional help and the fact that mental health needs surpass the available number of specialists to provide the required services (Theophilos, Green, & Cashin, 2015). A significant number of SAD patients fall into the category of people who suffer in silence hence it is imperative for psychiatric mental health nursing practitioners (PMHNP) to devices methods for easier diagnosis of SAD and also conduct education on SAD and its effect to vulnerable populations with focus on people living in northern latitudes where prevalence levels are high. Specialist nurses also provide pharmacotherapy intervention to patients that aid in reducing or eliminating disruptive symptoms of SAD and enable patients to live their lives to full potential. Research as part of improving the understanding of SAD and alternative intervention to improve patient outcomes also falls under the role of PMHNPs. 

Education 

Education on what SAD entails and its symptoms can help in the diagnoses and treatment of SAD. Increasing the public understanding of the condition will go a long way in differentiating SAD from winter blues. Specialist nurses have a role in developing programs for educating the public with emphasis on the key areas of prevalence, risk factors, symptoms, diagnosis, and treatment. Additionally, the number of specialists to handle such cases is dwarfed by the number of people in need of health. Hence primary health care providers need to be equipped with the necessary knowledge and skills to make correct diagnoses and recommend the right therapy for the condition. Skill improvement for the primary care providers can be achieved through education by the PMHNPs. 

Focus education on people in high latitudes is crucial in increasing knowledge of these populations about SAD. People in these latitudes receive very little or no sunlight in the winter months, with an average of fewer than ten hours of sunlight per day (Rohan et al., 2015). Thus, susceptibility is high for populations in this regions, warranting education on symptoms of recurrence which could likely be as a result of SAD. Other risk factors include age, family history and being female. Females are four times more likely to be diagnosed with SAD than males. Additionally, SAD has been observed to have an onset age of between twenty to thirty years (Kurlansik & Ibay, 2013). People with a family history of depression are also likely to develop SAD. 

Symptoms of SAD include constant feelings of worthlessness and depression on a daily basis especially in the winter months of between November to February. Very low levels of energy which causing a constant feeling of sleeping is also associated with SAD. A high craving for carbohydrate foods followed by weight gain due to overeating and inactivity. The symptoms disappear in late spring or summer but return in the next winter. Diagnosis from SAD must be done by a specialist on mental health or a trained primary caregiver. Self-diagnosis is likely to be erroneous. Two major treatment methods apply although other may also prove valuable. Light therapy and CBT have shown positive outcomes in the majority of patients. Other methods include psychotherapy, medications, and vitamin D supplements. Positive outcomes are often observed between one-two twelve weeks after commencement of treatment. 

Pharmacotherapy 

PMHNPs are trained to administer drugs to patients affected by SAD. Seasonal pharmacotherapy is the most common method where patients are administered with antidepressants about a month to the expected onset of symptom and then discontinued in the spring or summer (Avery, 2018). These antidepressants aid in control of the effects of unipolar depression which starts in the winter months and remits in the following season when it is left untreated. The PMHNP is better placed to monitor the response to drugs once they are administered. Patients are discontinued immediately any anomaly is identified. Incidentally, pharmacotherapy is not administered in isolation in most SAD cases. Light therapy or CBT are carried out concurrently to achieve desirable results. 

Research 

The existing literature gap on several aspects of SAD including the effectiveness of vitamin D in treatment, biological aspects, alternative treatment methods and other aspects warrant further research on the condition. PMHNPs have a role to fill this literature gap and also provide a breakthrough in methods of preventing the onset of SAD at its peak periods. Research can effectively device new methods of treating SAD within the shortest time possible. Furthermore, a complete understanding of the condition is necessary to eliminate uncertainty and confusion with other forms of mental illness. Populations in the northern latitude are most affected by the SAD owing to the minimal sunlight received in this areas in the winter months. Studies focusing on these populations can be vital creating a breakthrough on methods such as vitamin D and their role in preventing and treating SAD. Previous studies on the effectiveness of vitamin D supplements in treating SAD have returned inconclusive results Melrose, 2015). Furthermore, the specialist can also engage in interdisciplinary collaboration between nurses other mental health specialists can result in crucial findings and expand the knowledge base on SAD. 

Healthy People 2020 

Healthy people, 2020 is an ambitious yet achievable science-based plan launched in 2010 with the aim of achieving long and healthy lives for all people living in America (Department of Health and Human Services, n.d). The initiative outlines the goals and objectives of achieving this healthy status and longer goals. It also identifies specific and crucial areas that require action to meet the goals and objectives of the plan within the set timeframe. Consequently, the plan requires extensive collaborative structures between various health departments in the US. The Healthy People 2020 plan in line with the WHO organization assertion that mental health is crucial for a healthy population (Theophilos, Green, & Cashin, 2015). Emphasis on good health for the American citizens must not ignore mental health which affects a significant percentage of the population. The four overreaching goals in the plan are the attainment of longer lives free of diseases and injury, elimination of disparities in the health system, creation of an environment that promotes good health, and improvement in the quality of life through health promotion (Department of Health and Human Services, n.d). 

Public health requires a multidimensional approach where several factors such as ecological determinants of health, the role of information technology and hazard preparedness have to be taken into consideration in the policy-making process. It is in this regard that the objectives of the plan were formulated. Access to health services is a leading objective in providing quality healthcare to citizens. Improvement in mental health without ignoring young people is vital in creating healthy lives for people. Availability of preventive health services such as control of hypertension and diabetes which helps in reducing medical costs and time spent at healthcare facilities. The environmental quality which is indicated through the quality of air and livelihoods protects children as well as adults from the harmful effects of an unhealthy environment (Department of Health and Human Services, n.d). 

Accordingly, this project is designed to fulfill the goals and objectives of the health people 2020 plan with regard to the mental health of SAD patients. SAD has disruptive symptoms which affect the health and well-being of the individual and also prevent the individual from reaching their full potential in life. One of the overreaching goals of the plan is to attain longer lives that are free from disability and diseases. Thus, educating people living in the northern latitudes on the effects of SAD helps to help to improve diagnoses and treatment outcomes. SAD is a major form of depression that can have catastrophic effects such as suicide if it remains untreated, it also disrupts the life pattern of the affected party leading to some form of seasonal disability where the patient is unable to engage in daily routines. Health promotion aids in overcoming these setbacks in achieving the health status for individuals without diseases and disabilities. 

The other goal is to achieve equity through the elimination of disparities. Population in the northern latitudes are a greater risk of developing SAD than any other citizens in the US. Their susceptibility places them at a disadvantage when dealing with matters of mental health. Therefore health promotion strategies targeting these populations help to eliminate disparities in mental health for the general population. Health education promotes the quality of life by increasing the target population knowledge on SAD thus enabling them to seek professional help. It also improves health behavior of the population by keeping them informed of the risk of developing SAD and measures that they can undertake to protect them from developing the disease. Furthermore, this project facilitates the creation of a social environment that promotes good health among the target population. This social environment is a crucial store of knowledge on SAD and its effects. 

QSEN Competencies 

QSEN competencies are quality and safety standards for nurses aimed at reducing errors while caring for patients, improving nurses’ skills and creating collaboration within the nursing fraternity. In relation to SAD, these competencies have the overall impact of improving the quality of care that patients receive and also create positive patient outcomes from the treatment process. The six competencies defined by the standards are patient-centered care, teamwork, and collaboration, evidence-based practice, quality improvement, safety and informatics (Sherwood & Zomorodi, 2014). 

Patient-Centered Care 

Patient-centered care is founded on the pillars of communication, respect, and response to the needs of the patient and family needs (Sherwood & Zomorodi, 2014). This form of care takes into account the most effective method of method of caring for the patient while at the same time considering the method that the patient is most comfortable with at the time. Here, patients and their families are involved in making decisions about the expected care they should receive. Similarly, this project aims to make a patient-centered approach in determining the needs of the patients in the target population as well as their involvement in making decisions during the process. High prevalence levels of SAD in the high latitudes is attributed to lack of exposure to sunlight in the winter months. Thus, two possible explanations exist for the condition; lack of vitamin D and reduced levels of serotonin in the body. Selection of light therapy and vitamin B supplements might have the desired outcomes for patients. Additionally, preventive measures may involve natural means such as exposure to sunlight or artificial intake of supplements. 

Teamwork and Collaboration 

The benefits of teamwork and collaboration in nursing have been found to extend beyond the needs of the nursing practitioners and the patients to the organization (Souza, Peduzzi, Silva & Carvalho, 2016). Although professional training for mental healthcare specialist nurses majors on individual discipline, the work environment demands teamwork skills. Teamwork requires coordination of activities and efficient communication between team members. Educating the target group in the northern latitudes about SAD requires a team effort, engaging the effort of specialist nurses, social workers, and primary caregivers. The success of the process will hugely be determined by the ability of the team members to work together through sharing of knowledge and complementing each other’s skills. A proper understanding of the role of each team member is vital in avoiding friction and enhancing coordination. 

Evidenced-based Practice 

Evidence-based practice relies on scientific evidence and research findings to determine the best care for the patient. Mental health nursing practitioners rely on these findings when caring for SAD patients and carrying out public education programs. Studies have shown that light therapy and cognitive behavior therapy produce positive outcomes in over 70% of patients with SAD (Knapen, Van de Werken, Gordijn & Meesters, 2014). These findings support the viability of the two methods for treating SAD. Additionally, reliance on scientific methods informs decisions om pharmacology and improvements in nursing care. Evidence-based practice is thus useful in developing specific care techniques according to the needs of the given population or the patient. 

Quality Improvement 

This specific competency assesses the gaps that exist between the actual care that patients and the general population are receiving and the ideal care (Souza, Peduzzi, Silva & Carvalho, 2016). These gaps are then bridged to provide patients with the best care that is needed for the purpose of quality improvement. The idea behind focus education of the populations living in the northern latitudes is a quality improvement in the care and medical attention that they receive after developing SAD. The ideal care including the treatment techniques used on the SAD patients should be based on the patient’s needs. Application of modern tools and techniques of quality improvement is a sure method of improving the quality of care given to mental health patients. These tools identify specific areas of improvement with regard to mental health and assist in the process of laying down strategies to improve these areas. For instance, while assessing the ability of common treatment techniques for SAD, light therapy and CBT emerge as the most used methods. However, the success of these methods in SAD prevalent northern latitudes is not 100%. Hence, development of alternative methods like vitamin D supplements and pharmacology is crucial in improving outcomes. 

Safety 

Medical errors are costly and often have a catastrophic effect. In relation to mental health, errors can result in misdiagnosis or administration of therapies that are unnecessary or dangerous to the patients. Thus, safety measures aim to minimize or eliminate medical errors. When put into perspective, safety accommodates the needs of both the nurse and the patients. It involves the minimization of risk through improvement of the system and also the performance of individual nurses (Souza, Peduzzi, Silva & Carvalho, 2016). System performance in this case would involve the strategies that exist on identification of symptoms of SAD, diagnosis and treatment procedures. These procedures are implemented by caregivers in the healthcare sectors hence individual performances are pivotal in achieving the correct safety measures. Standardized methods developed for improving patient safety in mental health minimize the risk of misdiagnosis and also guide the specialist nurse on the type of treatment that is best suited for the patient. 

Informatics 

Patient care relies on evidence-based practice, patient safety and proper communication between practitioners. Thus informatics creates a link between the key QESN competencies. For example, patient electronic health record that are used to store patient records help to reduce risks, inform decision making with regard to care and provide an overall improvement in quality of care. Other informatics tools include literature searches for current data and latest findings, and quality improvement strategies. SAD is not a vastly understood condition even for specialists like PMHNPs. This, it is common to find new data and techniques for treatment developed from the latest research. Improvement of current methods is also common. PMHNPs, therefore, apply informatics to mine new knowledge and information for improving are afforded to SAD patients. 

Theoretical Framework 

Mental health is pivotal for the overall health and wellbeing of a given population. High prevalence of SAD in the population living in the northern latitudes can possibly derail the Healthy People 2010 plan and also minimize the potential of the affected people during the winter months. Therefore, providing education and professional healthcare solutions to this populations is vital in achieving mental wellness in these populations. 

Applying Neuman’s system theory of patient care, which incorporates a holistic approach in explaining the variables of a patients interact with their environment, it is possible to explain how health education targeting a given population can help to improve patient outcomes (Petiprin, 2016). Existing or potential environmental stressors have an impact on the nursing interventions with regard to intervention, attainment, and overall patient wellness. Neuman posited that preventions are the core of the primary intervention process. The natural environment contains stressors that can negatively influence the health of an individual. Thus, the purpose of the primary intervention is to keep stressors at bay or to these stressors from having a detrimental effect on the health of the patient. Primary intervention occurs before the stressors influence the health of the individual thus methods such as health promotion are applied. Secondary intervention then follows only if the individual has reacted to stressors. The center core which forms the basis of internal lines of defense is responsible for the well-being of the individual. The stressors weaken the internal core leading to poor health. The prevention process, in this case, is to strengthen this core to avoid damage to the wellbeing of the individual. Tertiary prevention strategies, which succeed the secondary strategies, purpose to add energy to the patient and assist in eliminating the impact of the stressors (Petiprin, 2016). These interventions also reduce the energy needed to return the patient to the original state. 

Neuman observed an individual as multilayered consisting of five different dimensions that interact to contribute to the wellness of the individual (Petiprin, 2016). All these dimensions are vital, and a weakness in a single dimension can topple the equilibrium in the person. The physiological subsystem of the body is responsible for the daily functions of the body including the organs and other all the other body parts. The psychological subsystem consists of mental process and emotional wellbeing. It is responsible for the mental process that helps to the individual’s mental health state. The socio-cultural part of a person relates to the interaction with others in the same environment. This helps in the learning process and accumulation of knowledge and skills that required at the time or in the future. The spiritual subsystem, on the other hand, creates a link between the physical body and spiritual beliefs of the person. These beliefs influence a person’s response to certain occurrences such as mental illness and therapy. Finally, the developmental subsystem which determines the onset of certain conditions and the body’s abilities to deal with changes that come with these occurrences. 

Ideally, nursing offers healthcare solutions to individuals, families and groups to maintain wellness in the general populations (Petiprin, 2016). Although the interventions may be group-based, the individual target is to maintain stability through elimination of stressors. Therefore, mental health specialist nurses have to assess variable that influences stressors that can destabilize an individual’s health system. Perception also matters in the process of assessing variables and devising methods of eliminating stressors. Both patient and nurse perceptions are crucial since they influence the healthcare plan and the success of these plans. Thus, the degree of reaction to stressors and how interventions at the three different levels influence wellbeing are key in a nurse’s roles. 

Several assumptions are in place when applying Neuman’s theory to the wellbeing of individuals and groups. Patients and groups are constituted of factors that inform the responses to the environmental stressors. Stressors are either known or unknown, and all have the ability to destabilize the wellness of individuals. Also, certain ranges of responses to these stressors have developed over time. The range of responses is used to develop standards that guide caregivers in determining how far the individual has deviated from the normal condition. In essence, the standards measure the severity of any given stress response. Although individuals have a line of defense against the universal stressors, the stressors sometimes breach this line leading to secondary and tertiary interventions. These breaches impact on the energy exchange between an individual and the environment, hence interventions are meant to stabilize this energy exchange. 

Significance to SAD Education 

Environmental stressors responsible for the development of SAD in people living in the northern latitudes are insufficient or absence of sunlight leading to deficiency of vitamin D and low levels of serotonin in the body. This interaction between the body and the environment is akin to Neuman’s entropy explanation, identifying the energy depletion process which ultimately results in illness (Petiprin, 2016). Furthermore, the three basic forms of intervention explained by Neuman are an application in the education process for susceptible people. Primary intervention whose main role is to keep stressors, as well as the body, responds to stressors from causing illness is achieved through health promotion. Similarly, health promotion strategies for SAD will focus on encouraging people to gain exposure to sunlight and also minimize situations that are likely to lead to the development of depression. Secondary interventions which are suited for post-exposure to stressors will be in the form of measures to eliminate detrimental effects due to lack of sunlight exposure. These include supplements and medications such as antidepressant that is taken before the onset of winter. Tertiary interventions constitute methods of treating SAD once it has already occurred, these include light therapy, CBT and other alternative methods that seek to restore the patients’ health to the original level. 

Comparatively, Neuman’s multidimensional being approach is critical in understanding individual’s perceptions about SAD and the treatment methods that are suited for the population. This approach also informs the specialist’s decisions on treatment methods for the population. The psychological subsystem is vital in maintaining the balance in the body’s physiochemical structure, hence is vital in understanding how serotonin and melatonin levels impact on SAD. The human psychological part which controls emotions is responsible for the most of the observable symptoms of SAD. SAD causes anomalies in the psychological subsection. Sociocultural factors also play a huge role in SAD education. Social interaction is minimal during the summer months due to weather. For people prone to depression, these are risk factors that are likely to cause SAD. Spiritual wellbeing on the other hand influences perceptions about the treatment available for SAD patients and their success rate. 

Implementation 

Setting 

This SAD education project will focus on populations that are above the 450N latitude in the US. They include Washington, Montana, North Dakota, parts of Minnesota and Alaska. Studies have shown that these northern latitudes experience considerable variations in photoperiods, hence the correlation between SAD prevalence and latitudes together with the severity of symptoms (Sandman et al., 2016). Photoperiodic variations in these locations cause the regions to receive minimal sunlight in the winter months. An average of ten hours or less of sunlight per day significantly reduces the timeframe that residents are able to gain exposure. Synthesis of vitamin D requires an exposure period of about thirty minutes, however, given the photoperiods for these locations in the winter months, and the climatic conditions it is almost impossible for residents to get sufficient skin exposure. Lack of sunlight is a precursor for SAD, hence the setting for this SAD education project. 

Prevalence levels for SAD in these regions are as high as 10% of the general population (Kurlansik & Ibay, 2013). Comparatively. Only two percent of the population in low latitudes is affected by SAD. As part of the goals of the ‘Healthy People 2020’ plan to eliminate health disparities between people living in America, SAD education in the northern latitudes aims to reduce the prevalence of SAD in the northern latitudes regions and increase access to professional help. Susceptibility to SAD without adequate knowledge on the population increases the risk of failure to seek medical help due to the assumption that the symptoms are brought about by winter blues. Furthermore, health promotion with regard to SAD in the regions enables the seeking of alternative means to control the conditions. Environmental factors that are sunlight and harsh weather conditions are beyond the control of the residents. Hence alternative methods are more likely to work and assist in reducing SAD prevalence levels. 

Population 

States in the northern latitudes in the US have a combined population of about nine million residents. Washington is the most populous of the regions due to the urban setting with a population of about seven million. The other states have populations ranging from 600,000 to 900,000. Incidentally, urban settings have been observed to have higher prevalence levels of SAD as compared to rural settings (Sandman et al., 2016). This observation is best explained through the daily schedules of urban residents. Urban dwellers are more prone to stress due to their living conditions and daily schedules which allow minimal time for entertainment and exercise. This limit the time for exposure to sunlight hence higher cases of SAD. 

The targeted population for SAD education in these regions are young people who are at risk of developing SAD. SAD has a common onset in people who are between twenty and thirty years. Effectively, these are young people who are expected to be healthy and at the peak of their abilities. This societal perception results in many SAD patients within the age bracket to tough it out with SAD symptoms. In cases of acute SAD, the patient often fails to seek professional help. The acute symptoms may develop into severe depressions. Typically, acute SAD clinical symptoms are common in the northern latitudes. People within the targeted age bracket form around 20% of the targeted population for this program, and are well versed with the internet. Thus, about 1.5 million youth are expected to be reached and impacted by the SAD programs in the mentioned regions. The role PMHNP in this program is to formulate strategies that will aid in easier and efficient passage of the intended message to the population. 

Description and Design 

The SAD Health Education program will aim to improve mental health outcomes for young people who are at risk or already affected by SAD in the regions of Washington, Montana, North Dakota, parts of Minnesota and Alaska. Given the geographical size of the targeted regions and the population to be served with the message, it is imperative to develop a health promotion method that is both appealing to the target population and meets the goals of the education program. Interventions in health promotion are successful if they are tailored to the need of the target audience (Head, Noar, Iannarino & Harrington, 2013). Therefore, health education for this population should focus on the age bracket, the health needs of the young people and the level of understanding that the population has with regard to mental health. Elimination and ambiguity while also keeping the message brief are vital in keeping the appeal of the message. Importantly, maintaining a considerable form of professionalism in relaying the message and providing feedback is crucial in gaining the trust of the audience. 

Traditional health promotion strategies are less appealing to in the current generation of youth, therefore, can easily be ignored or easily forgotten. As a result, the PMHNP has to be well versed with modern techniques that not only harness the modern technological appeal but also create opportunities for easier feedback when required. Current populations are more concerned about individualized health care as opposed to generalized perceptions about mental health. For instance, two young people affected by SAD may display the common clinical symptoms of the conditions but may require different levels of therapy. Additionally, the response to therapy is significantly affected by a myriad of other factors that are related to the condition such as sociocultural factors and spiritual wellbeing. Thus, perceptions and expectations have a huge role to play in the mental health promotion program for SAD. 

Social media has emerged in recent years as a useful tool for conducting health promotion programs (Korda & Itani, 2013). The importance of social media in health promotion is supported by advancement in communication techniques through the internet thus allowing for participative communication. Technological advancements have also made it possible o access social media sites like Facebook and Twitter from a variety of gadgets. This project intends to harness the resources available in social media to promote mental health wellness among the targeted population in the northern latitudes. Strategies that are suited for social media mental health promotion method will be used applied. Social media offers the benefits of interactive communication which is difficult to achieve with other media used in mental health education. This program will exploit this avenue by providing interaction between the user and a PMHNP. The targeted population of over 1.5 million young people between the age of 20 and 30 cannot be easily accessed through physical methods of health promotion. Social media helps to overcome this challenge by allowing mass communication at little cost. 

A PMHNP will lead design of the messages to be relayed through social media platforms like Twitter and Facebook. A specialist input is mandatory to ensure that the nature of information relayed is not just reliable but useful in the context that it is used. Designing of the message will follow specific guidelines that begin with background knowledge on SAD, symptoms, diagnosis, treatment, and prevention. 

Providing background information about SAD aids in acquitting the audience about the condition and its nature. A significant number of people are unaware that mental health constitutes the overall wellbeing of a person. Information on the occurrence, the prevalence in the specific regions and the importance of this knowledge form the foundation for the other aspects of the education program. The seasonal nature of SAD with symptoms that appear in the winter months and disappear in spring or summer will equip the audience with the knowledge that will facilitate the process of seeking professional help for those affected by the condition. SAD manifest through clinical symptoms of; low energy levels, trouble sleeping, increased appetite, feelings of worthlessness and weight gain in winter months. The target audience becomes interested in these symptoms to inform their decision on whether their situation or one which they have observed before matches the description. Knowledge of these symptoms is also vital in creating an information base that may be useful in future in case any of the symptoms appear. Importantly, the symptoms remit in spring or summer and again appear in winter. 

Diagnosis for SAD should be conducted by a specialized, in this case, a PMHNP or a specialist doctor. Symptoms may be similar with those of other conditions like unipolar or bipolar disorders. Thus, suspected cases of SAD require a specialist’s assessment to ascertain the existence of the condition. Since prevalence levels are high in the northern latitudes, any of the symptoms noted must not be assumed for winter blues. Professional assistance is also necessary in the event that the symptoms identified might be related to any other form of mental illness. The diagnosis process also allows for assessment of the severity of the condition to determine the therapy required. 

Treatment regimens for SAD include light therapy, CBT, pharmacology and vitamin D supplements (Nussbaumer, 2015). Light therapy is the most common technique for treating SAD with positive outcomes in over 70% of the patients (Knapen, Van de Werken, Gordijn & Meesters, 2014). Information on the available methods for SAD treatment creates an understanding of main treatments, which is light therapy and CBT, therefore enabling patients to make informed decisions of their preferable choices. Incidentally, a significant portion of the population does not respond to light therapy. This warrants provision of information on the available alternatives in such situations. This information is in line with the QESN competency of patient-centered care where the PMHNP consults the patients to determine the best type of care suited for them. 

The suitability and success of vitamin D for treatment of SAD provides hope for most patients due to the ease of administration of the supplements and their effectiveness. Vitamin D synthesis occurs naturally due to skin exposure to sunlight. Given that the northern latitudes receive little or no sunlight during the winter month, vitamin D deficiency contributes to the high prevalence of SAD in the northern latitude regions. Studies have effectively linked lack of sunlight exposure to major types of depression. Hence, vitamin D is vital for mental wellness. Supplements can help the body retain the physiochemical balance hence aid in treating SAD. 

Prevention strategies are also crucial in avoiding the disruptive characteristics of SAD symptoms. SAD has the potential to limit a patient’s potential by causing a lack of interest in activities that would otherwise seem interesting on normal occasions. Furthermore, low energy levels prevent the accomplishment of daily activities. Preventive measures include deliberate exposure to sunlight when possible to activate vitamin D synthesis in the body. Other measures include administration of antidepressants before the onset of winter. Social interaction is also helpful in avoiding the lonely situation that may cause deterioration of symptoms. 

Relaying this information through social media platforms will require dissection into small bits that are less tedious to read and also easily understandable. Use of simple wording while avoiding ambiguity enables easier remembrance for the audience. Furthermore, an avenue will be provided for feedback such that the PMHNP will make queries, concerns, and clarification. 

Timeline for Development 

This SAD education program will run for three months with key components of the program being accomplished periodically. The program will commence in October before the onset of winter and run for two months. The timing of the education program to coincide with the beginning of winter is to equip the target population with information that will facilitate identification of symptoms and enhance the process of seeking professional help. It is also well suited for increasing diagnosis of the condition since most of the young people in these regions remain untreated for the condition. 

The first week and second will involve the formulation of the work plan, drafting of the plan itself and familiarization with the target population. The work plan will outline the process for carrying out the program from start to completion. Drafting the plan will follow the professional outline of mental health education with an emphasis on available scholarly research for evidence. The second week will involve familiarization with the target population, the demographics, and the health needs. Activities for the third week of the program will include identification of social media platforms for relaying the message, laying down of the specific infrastructure and involving the targeted audience in conversations together with announcements on the launch of the SAD education program. After ascertaining that all the infrastructure is ready and the expected audience reception is excellent, the program will launch in the fourth week. 

Continuous education strategy is suitable where information will be disseminated in bits while allowing for feedback. The process will go on until the end of the last two weeks of the program. Responses will be noted throughout together with adjustment to make the program successful. The evaluation process will then follow to determine the impact of the SAD education on the young people in the northern latitude regions. 

Plan for Evaluation 

An impact evaluation process will determine the success of the health promotion program. An impact evaluation follows the process of assessment of fulfillment of set goals and objectives together with a change in the awareness levels, population attitude and increased knowledge (Neiger, Thackeray, Burton, Giraud-Carrier & Fagen, 2013). The goals of the SAD education program were to increase the percentage of the people between 20 and 30 years seeking professional help for SAD related symptoms, increase alternative treatment outcomes for SAD patients using vitamin D within the same age bracket and to reduce prevalence rates of SAD in the regions of Washington, Montana, North Dakota, parts of Minnesota and Alaska. The objectives are to create knowledge and awareness on SAD and its impact on the daily lives of the patient, provision of knowledge on treatment and prevention of SAD. 

Attainment of the set goals will be measured through the data that will be collected from state and regional offices for mental health records. Outcomes of the use of vitamin D supplements either independently or in combination with other methods will be sampled from various facilities in the region. The full impact of the knowledge disseminated to this population will not be possible in the short term. Thus, measuring the influence of this information at the end of the program is impossible. However, the impact can be measured in the future through the prevalence levels of SAD in people of the targeted age bracket. 

Expert Reviewers 

Expert opinion of what constitutes a good mental health education program is vital in assessing the impact that this plan will have on the population (Korber & Becker, 2017). Mental health experts in the US concur with the findings that challenges associated with mental illness are not accorded the attention that they deserve. Furthermore, reviewers’ opinions are vital in providing crucial information that might be added to the program for future education of other population or studies on SAD. Three reviewers from different mental health disciplines will assess the suitability of this study. A trained PMHNP, a practicing psychiatrist based in the northern latitude regions and a psychotherapist also based in the same region. The assessment will be conducted through scheduled interviews. 

Expert Review 

Mental health education program are conducted with the aim of improving the psychological well of the given population. Different mental wellness progress have had varied levels of success in the past. Determinants of the success or effectiveness of a mental health education program are reachability of the target population, the cost-benefit of implementing the program, and evidence of the impact of the program (Korber & Becker, 2017). Mental health experts view these three main factors as the correct measures of the effectiveness of a mental education plan. Compared to this SAD education program, these three measures perform considerably well when put into perspective. Reachability is the ability of the message to reach the intended audience in an undistorted manner while also remaining understandable. The chosen regions for this study have a significant social media use that contributes to the reachability aspect. Additionally, the utilization of the two social media platforms, Twitter and Facebook ensured that the message was relayed to a majority of the targeted population. 

Cost-benefit of a mental health education program compared the economic value of the input to the program with the value output which is the benefit that the program offers to the population. Harnessing the power of social media to educate the population on SAD is a cost-effective method considering the financial and knowledge input. Social media facilitates communication among thousands or millions of people at a fraction of the cost of other methods of health promotion. Social media also has the added advantage of interactive communication where an avenue for direct interactions and feedback is available. Health facility and local health records provide evidence of the impact of a mental health promotion program. These are the diagnoses, treatment, and outcomes of the particular regions over a specified time. The impact can either be long term or short term. In this case, the short-term impact is the number of diagnoses and successful outcomes in the winter months after the program while the long-term impact is assessed through the level of prevalence of SAD after a year or more. 

Discussion 

Mental health contributes to the overall well-being of an individual. Achieving the goals of a ‘Healthy People 2020’ plan requires a significant investment in the mental health of people living in America. SAD is one of the leading causes of mental illness in America, warranting an investigation into the causes and available treatment options. People living in the northern latitudes are most affected by SAD due to the photoperiodic variations in these regions. Sunlight exposure is responsible for vitamin D synthesis which affects serotonin and melatonin levels in the body. Disequilibrium in the levels of serotonin results in circadian phase delays hence the development of SAD. Consequently, adequate sunlight exposure for people who are susceptible to SAD is vital in preventing the development of the condition. Studies are yet to conclusively determine the benefits of vitamin D supplements in enhancing mental health, although studies on small populations have indicated positive results. Therefore, in the right quantities, these supplements can significantly help in reducing prevalence levels in northern latitudes. 

Limitations 

The limitation of this program is the method used to reach out to the target population. SAD has an onset of between 20 to 30 years hence this program targeted people of this age group in the mentioned region. However, social media users can effectively provide information that is not verified. This poses a problem in this program due to the inability to verify this information. Still, the number of users who provide false information is not significant to derail the outcome of the education program. 

Strengths 

The strengths of the SAD education program is the social media avenue used. Social media permits interactive communication with the PMHNP thus feedback provided may be used to determine the impact of the program. Social media is also a cost-effective method of health promotion that allows for health promotion at minimum costs. 

Conclusion 

SAD can be effectively treated in the majority of the patients using the available treatment methods. Although the available literature effectively links SAD to insufficient exposure to sunlight, further research is necessary to increase the knowledge base of the physiological occurrence ultimately lead to emotional instability. The “Healthy People 2020” is only achievable if mental health is accorded the right amount of attention. Additionally, increasing the number of mental health specialist will go a long way into improving the mental health of citizens. Further research is also required on the importance of vitamin D and how it can be effectively used in treatment of SAD. 

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