Sarah, a 38-year-old lawyer, was 50 years old
milligrams of sertraline for two years when he came to my office. His
depression had raised, but his libido, energy and emotion
I was not fully back. “I want to get off these drugs,” he told me.
“But every time I try, I feel worse than before I started.”
Sarah is not unique. One in six adults takes an SSRI. Many were
It started with a 12-minute visit. Almost no one is told how to stop.
Health Secretary Robert F. Kennedy Jr. recently announced the initiatives
to assist them in: training the clinician, CMS code for description, and a
Dear Colleague Recommendation Letter eatingexercise, social
connection, and psychotherapy as alternatives.
An overlooked alternative: exposure to morning light
The letter of the dear colleague left an alternative on this topic
biology under diagnosis. This is an alternative
dosed, timely exposure to external light, especially in the morning.
About half genes in the human body is turned on and off by a
internal clock. This clock is set primarily by touching the back of the light
of the eye, and strengthened by when you move and eat. Break the clock
and you break appetitecortisol rhythm, social energy and
brain circuits that control rumination.
PubMed returns over 7,000 articles circadian rhythms and
depression. Dear Colleague’s letter does not mention any of them.
Depression is not a single disease. In a quarter of patients with depression
early-onset circadian subtype, more severe symptoms, and a
Measurably worse response to SSRIs and SNRIs. These are
Patients asking how to stop a drug it never fully worked. They are
has known, free, scalable treatment. So far no one has told them.
Overprescribing is part of the problem. The rest is that
the tool with the best evidence is missing from the toolkit and
the lowest price in the literature.
Clinical trials comparing light therapy and Antidepressants
In 2016, Raymond Lam and colleagues randomized adults
to an unseasonal major depression placebofluoxetine, bright light
fluoxetine alone or in mild excess. A mild fluoxetine kick. The
the combination defeated both. Number needed for treatment
The combination arm was 2.4, better than most pharmaceuticals
market for all conditions.
I have been prescribed SSRIs and will continue to do so. For severe depression
they save lives. Lam’s test showed that light and drugs also beat
alone, that’s the point. But not as useful as pharmaceuticals
suggested ads. SSRIs have three times the risk sexual
dysfunction. About one in six patients has another significant side
effect when suspended.
Most people have never heard of daylight screen time as
alternative. Within an hour of waking up, go outside before touching
your phone. Do not wear sunglasses. Find the view of the sky because the light
what is needed is the eye, not the scenery. Cells on your back
the eyes that help set the circadian clock care about how much of the sky you can see.
Leave for at least 10 minutes. If possible, repeat at lunch.
One exception: patients bipolar disorder must be consulted a
Before the psychiatrist dosed the morning light, it could advance the circadian rhythm
phase fast enough to trigger mania.
In winter, it works during the day before the screen. External light a
still 10,000 lux or more on a gray, rainy morning, 300 lux
the brightest office. Door, balcony, fire exit, open window,
bus stop, covered porch all deliver the dose. Without sunglasses or
sitting near a closed window or in a vehicle.
A patient with seasonal depression in Buffalo doesn’t need to act
to Phoenix. He has to go out the back door with her at 7 in the morning
coffee and see above.
If CMS pays to reduce antidepressants, it should pay for the prescription
ten minutes in the morning sky during that cone. time, duration,
skyview and frequency should be like recipes in the script
is written. If SAMHSA builds without training modules this summer
the basic chronobiology in them, the panel forms the same gap
Dear colleague prepared a letter. 50 million Americans remain
They say the only door out is the door they come in.
For Sarah, the recipe was clear. Coffee on the back step, not
on the kitchen counter. Within an hour of waking up, the sky in his eyes,
before his phone. Walking lunch three days a week. We have shortened it
sertraline for four months. He couldn’t help himself now. He is also outside
on purpose, every day.
16% of American adults take over-the-counter medications
it will be difficult to stop them. Dosed, deliberate, timed
is included in the list of outdoor activities. It is past time we prescribed it.
