There’s no doubt that the COVID-19 pandemic has triggered an uptick in mental health issues for all kinds of reasons. There’s fear and anxiety about getting sick, depression from social isolation, financial hardship, and months of disruption to our everyday lives and routines — as well as the physical distress and cognitive side effects of actually contracting the virus.
What’s more, COVID-19 cases are surging throughout the United States and around the world during a time in which people are prone to seasonal affective disorder (SAD), which tends to appear in the shorter, darker days of winter.
If you live with chronic pain or an underlying medical condition, you recognize that you may face even greater challenges in protecting your mental health during this time.
Here’s everything you need to know about depression during the winter season, chronic illness and pain, and the COVID-19 pandemic — and the steps you can take to start feeling better if you recognize that you’re experiencing symptoms of depression.
Seasonal Depression: The Role That Winter Plays in Mood
You may normally feel less energetic, motivated, and chipper during winter months. However, these common “winter blues” are different from seasonal affective disorder (SAD).
“It’s hard to distinguish the differences between SAD and the winter blues by yourself,” says clinical psychologist Laurie Ferguson, PhD, Director of Education Development for the Global Healthy Living Foundation (GHLF). “With the winter blues, you can shake yourself out of it. Those feelings come and go. But if you find that you persistently feel sad or hopeless, and those feelings arise the same time every year, it could be SAD and you need to seek professional help.”
Seasonal affective disorder is a type of depression that begins and ends around the same times every year, per the Mayo Clinic. It most commonly occurs in the winter months but can also strike in the spring or early summer.
“While the ‘winter blues’ don’t feel good, they wouldn’t be what we call a real depression,” says Jason Levine, PhD, a licensed clinical psychologist based in West Los Angeles. “Seasonal affective disorder, on the other hand, is considered a depressive disorder. It also just so happens that this depression follows a seasonal pattern, and it doesn’t have to be winter.”
Causes of Seasonal Affective Disorder
While the exact cause of SAD is still unknown, some factors that may play a role include the following, per the Mayo Clinic:
- The reduced amount of sunlight in fall and winter can disturb your circadian rhythm, or your body’s internal clock, which can lead to feelings of depression.
- Less sunlight causes a drop in the brain chemical serotonin, which may trigger depression.
- The changing seasons can disrupt your balance of the hormone melatonin, which affects sleep patterns and mood.
SAD is diagnosed more frequently in women and younger adults than in men and older adults.
“Typically, you know if you’re prone to seasonal affective disorder by your early 20s,” says Dr. Levine. “People don’t tend to all of a sudden get this in their 40s and 50s — that’s very rare.”
Factors that may increase your risk for SAD include family history, living far from the equator, and having major depression or bipolar disorder.
Symptoms of Seasonal Affective Disorder
SAD shares several symptoms with depression since it’s a type of depression itself, according to the Cleveland Clinic. Two clues that you’re experiencing SAD specifically are if depressive episodes occur during specific seasons for at least two consecutive years and if depressive episodes happen more frequently during a specific season than during the rest of the year.
However, it’s important to see a health care provider for a thorough evaluation rather than trying to diagnose yourself. Symptoms of SAD include:
- Carbohydrate cravings and weight gain
- Extreme fatigue and lack of energy
- Feelings of hopelessness or worthlessness
- Inability to concentrate
- Limbs feeling heavy
- Loss of interest in usual activities, including withdrawing from social activities
- Sleeping more
- Thoughts of death or suicide
Depression and Chronic Illness
Meanwhile, it’s estimated that one-third of people with a chronic illness or condition experience symptoms of depression, per the Cleveland Clinic. While any type of chronic illness can contribute to depression, those that are more severe or cause more disruption in one’s life have a higher risk.
For instance, the rates for depression in those with these medical conditions are very high, according to the Cleveland Clinic:
- Heart attack: 40% to 65%
- Coronary artery disease (without heart attack): 18% to 20%
- Parkinson’s disease: 40%
- Multiple sclerosis: 40%
- Stroke: 10% to 27%
- Cancer: 25%
- Diabetes: 25%
Estimates for the rate of depression in arthritis vary. According to the U.S. Centers for Disease Control and Prevention (CDC), about one in five adults (20 percent) has symptoms of depression or anxiety, but these rates are likely higher among people with different types of arthritis or depend on the severity of the condition and its impact on quality of life.
For example, a January 2017 review published in the journal Expert Review of Pharmacoeconomics & Outcomes Research found that the prevalence of depression in rheumatoid arthritis patients can be as high as 66 percent.
Meanwhile, a September 2013 systematic review and meta-analysis of 72 studies published in the journal Rheumatology estimated that the prevalence rate of significant depressive symptoms in rheumatoid arthritis patients was nearly 40 percent.
“There are neurological, biological, and environmental factors in upbringing that play a role in chronic illness patients developing depression,” says Rebecca Solodovnik, MHC-I, a mental health counselor at NYC Counseling, who was diagnosed with type 2 diabetes at age 13 and developed depression as a result.
“For instance, you may not have the tools or equipment from your past to cope with a chronic illness diagnosis,” Solodovnik continues. “Or you might experience a lot of stress from feeling vulnerable or losing your ability to do certain things, which can affect brain function.”
Chronic pain alone may contribute to a vicious cycle with depression.
“If you have chronic pain, say, with arthritis, one of the questions we have is: Does depression cause pain, and does pain cause depression?” says Dr. Levine. “I think the answer is essentially yes to both.”
“Pain can cause difficulty sleeping and stress if you continue to have it, and that can lead to depression,” Levine continues. “Also, depression can prime you for hypervigilance and sensitivity to pain.”
Because these factors are typically intertwined, it can be difficult for patients with chronic illness to get the correct diagnosis.
“Depression often goes undiagnosed in people who have chronic pain, because there’s a lot of overlap,” says Dr. Levine. “If you’re not sleeping well, a medical doctor may often put that down as being due to your chronic pain, when actually a large part of the reason for that may be depression.”
The Intersection of SAD, Depression in Chronic Illness, and the COVID-19 Pandemic
People who are already prone to depression due to chronic pain or an underlying disease may also be prone to SAD or depression related to the COVID-19 pandemic, says Dr. Ferguson.
“It certainly would be possible that anything that contributes to a down mood or string of gray days will wear on somebody,” says Dr. Ferguson. “If you’re already dealing with pain, it would make sense that being sensitive to changes in light would deepen that sense of depression, of being closed in, and not being able to have your own energy.”
On top of that, the stress and isolation the COVID-19 pandemic has brought on can further impact those with SAD or depression caused by an underlying condition.
“I think people are very tapped out, and when you have already been dealing with chronic pain and chronic illness — and you can’t use your usual coping mechanisms like socializing — that added burden is significant,” says Dr. Ferguson. “I’ve seen this a lot with my clients.”
Socializing as a coping mechanism for depression goes beyond talking with or seeing friends or family members. It can involve simply being part of your community or chatting with strangers as you go about your day. And this isn’t possible for many people right now, especially those who are staying home as much as possible because they’re high-risk for COVID-19 complications.
“That human contact includes getting a cup of coffee at the store you always go to, where someone knows your order and says hi,” says Dr. Ferguson. “It’s stopping to talk to your neighbor on the street, and just being out and about and feeling like part of the world. That’s socializing as well.”
Much more research is needed to determine the exact association between risk of depression and the COVID-19 pandemic, but early reports show a link.
“Because the pandemic has not been around for a long time, there are a lot of hypotheses around its impact on mental health,” says Dr. Levine. “But if we look anecdotally, all kinds of mental health disorders are made worse by the pandemic, including depression, anxiety, substance use disorder, and likely seasonal affective disorder.”
Almost a year after COVID-19 began spreading around the world, more than half of American adults (51 percent) said that worry or stress due to the pandemic has had a negative impact on their mental health — with one in four saying it has had a major impact, according to the December Kaiser Family Foundation Health Tracking Poll. That is higher than in May 2020, in which 39 percent of adults said the pandemic had a negative impact on their mental health.
In the July 2020 edition of the poll, many adults reported specific negative impacts on mental health and well-being such as difficulty sleeping (36 percent) or eating (32 percent), difficulty controlling their temper (18 percent), increases in alcohol consumption or substance abuse (12 percent), and worsening chronic conditions (12 percent) due to stress about the coronavirus.
How Getting Sick with COVID-19 May Affect Your Mental Health
Beyond the societal effects of the pandemic (such as social isolation or financial hardship), the virus itself appears to be causing mental illness in people it infects.
A new review in The Lancet found that nearly 20 percent of COVID-19 patients developed a mental issue such as depression, anxiety, or dementia within three months of their diagnosis — double the risk of those without COVID-19.
To come to these findings, researchers analyzed data from 69 million individuals, 62,354 of whom had a COVID-19 diagnosis. They also found that having a psychiatric disorder in the year before receiving a COVID-19 diagnosis was associated with a 65 percent higher chance of getting the disease.
“Survivors of COVID-19 appear to be at increased risk of psychiatric sequelae [consequences], and a psychiatric diagnosis might be an independent risk factor for COVID-19,” note the researchers.
That risk was present even when physical risk factors and housing and economic circumstances were controlled for. The researchers say that possible explanations include behavioral factors like less adherence to social distancing or residual socioeconomic and lifestyle factors (like smoking) that may not be sufficiently captured by available data in the studies.
It’s also possible that COVID-19 vulnerability is increased by the pro-inflammatory state that may occur in some forms of psychiatric disorder — or it could be related to medications used for psychiatric disorders.
COVID-19 appears to have a wide range of effects on the brain, ranging from brain fog to life-threatening strokes, per Johns Hopkins Medicine. While experts don’t know why this is quite yet, there are several theories that need more research before conclusions are made:
- The virus may be able to enter the brain and cause a sudden and severe infection (viral COVID-19 particles have been found in brain cells).
- The immune system might overreact to fight COVID-19, producing a harmful inflammatory response that may cause more tissue and organ damage than the virus itself.
- The many physiological changes that can occur in the body during COVID-19, from high fevers to low oxygen levels, may contribute to the brain dysfunction seen in severe COVID-19 patients.
- Blood clots are much more likely to occur in COVID-19 patients than in others, which can cut off blood flow and lead to stroke.
How to Get Help If You Have Seasonal Affective Disorder or Depression Symptoms
No matter what may be contributing to feelings of depression — be it COVID-19, an underlying condition or chronic pain, or seasonal affective disorder — the most important thing is that you seek help if you are experiencing symptoms.
“I think it’s futile and frustrating to imagine we could really get to what’s causing depression, because there are so many things happening right now,” says Dr. Ferguson. “I don’t think there’s any point trying to figure out which is the worst part of it. The bottom line is, get help.”
It’s important to talk to your health care provider about any concerning symptoms you experience, even if you feel like “everyone” is going through tough times right now.
“I encourage people who are possibly experiencing depression or seasonal affective disorder to seek out an experienced and licensed professional who understands both depression and SAD for an appropriate assessment, proper diagnosis, and the offer of appropriate treatment options to help reduce the power of these symptoms,” says Dr. Levine.
A doctor or therapist may recommend medication, therapy, and behavior and lifestyle changes to help manage depressive symptoms.
Here are steps experts recommend taking if you find yourself experiencing symptoms of depression.
1. Find someone to talk to
It’s simple, but easy to forget: Connect with someone and express yourself, even if it’s virtually.
“You are not a whiner, you are not a person who can’t cope, you’re not weak, and you’re not a failure,” says Dr. Ferguson. “Talking with someone who is empathetic and warm and allows you to just be as you are can really help and is an enormous relief.”
You may worry that by telling a loved one how you’re feeling, you’ll sound like you’re complaining — especially during a time when so many are struggling. However, your situation is unique and you deserve the opportunity to talk about what you’re going through.
“Understand that living with chronic illness is a more intense burden right now than someone else who is just dealing with the pandemic,” says Dr. Ferguson. “You’re entitled to ask for help.”
If you’re still worried, tell your loved one that you’d really like someone to talk to. Ask them if it’s a good time for them to talk, and if not, ask if you can set up a time to talk together later. “The reality is that most people want to help,” adds Ferguson.
Also know when it’s time to see a therapist for professional help.
“If you really can’t pick yourself up for five to seven days, and you feel like nothing is ever going to change and life is going to be like this forever, you really need to get help,” says Dr. Ferguson.
A therapist may use combinations of such psychotherapy techniques as:
- Cognitive behavioral therapy (CBT), which helps you become aware of negative or inaccurate thought patterns so you can more effectively respond to challenging situations.
- Acceptance and commitment therapy (ACT), which focuses on accepting your deeper feelings as appropriate responses that shouldn’t keep you from moving forward.
- Dialectical behavioral therapy (DBT), which emphasizes mindfulness, distress tolerance, interpersonal relationships, and emotional regulation to help patients who suffer from self-destructive behaviors.
Research shows that mindfulness practice like meditation can help with depression and anxiety, per the Mayo Clinic. Your therapist may recommend that you practice mindfulness through exercises like body scan meditation (focusing on your body from head to toe), deep breathing (focusing on your breath), and walking meditation (focusing on the sensations of your body as you move through your environment).
“Activating a mindfulness technique is what can bring you back to the present moment, creating logic and calm for you,” says Solodovnik.
However, your doctor may recommend a wide variety of strategies for you to try.
“As a psychologist, I say that I’m going to give you a lot of tools, but I’m not concerned with which ones you gravitate toward,” says Dr. Levine. “Whichever ones you relate to the most, those are the tools you should use.”
“For some people, it’s exercise-based like walking or yoga, while for some people it’s a mindfulness practice like deep breathing,” he continues. “Other people are more thought-driven and may engage more in psychotherapy.”
2. Talk to your health care provider about medication
Your physician can help determine if you’re a good candidate for antidepressants or other medications to manage depression. They can also pinpoint the timing of your medication if you have SAD — say, if you should take antidepressants each year before you start to experience symptoms, or if you’ll need them beyond the time your SAD symptoms typically fade away.
“These are times with unprecedented stressors, and tending to mental health is imperative,” says Dr. Ferguson. “There are many ways to do that and they are specific to the person and their medical story, but making sure you get support in whatever way is best is essential.”
Your doctor may recommend antidepressants such as selective serotonin reuptake inhibitors (SSRIs), which can ease symptoms of moderate to severe depression by raising levels of serotonin (a chemical that carries signals between brain cells) in the brain, per the Mayo Clinic.
3. Get outside every day if possible
Even if it’s just enjoying a stroll around a courtyard or your neighborhood block, try to move outside of your normal environment every day.
“If it’s possible given your physical circumstances, get outside for even 10 minutes a day to stand in the sun,” says Dr. Ferguson. “Even if you are often in pain, moving around and being outside can help.”
If you’re experiencing season affective disorder, your doctor may also prescribe light therapy for anywhere from 30 minutes to two hours per day. Here, you sit in front of a special type of light called a light box while you work at a computer, read, or eat meals, per Michigan Medicine. Light therapy is an effective treatment for SAD and has few side effects.
When you can’t leave your home, making little changes to your indoor environment can give you a mental boost that might be helpful.
“Psychological organization helps a lot of people feel better physically as well, so shift and reorganize things around your home,” says Solodovnik. “Move things around in the home and let go of items by donating them.”
If you find it hard to muster up the motivation to do so, start with what Solodovnik calls “small bites.” Make your bed, shower daily (and perhaps treat yourself to a new shower gel or shampoo to get you motivated), move your desk chair to be closer to sunlight, light a candle, or display a picture that brings you joy.
4. Do little things you enjoy
Whether it’s listening to your favorite song, putting fresh flowers on your kitchen table, reading a book for pleasure, or enjoying a soothing face mask (the aesthetic kind — not the COVID-19 protecting kind) at the end of the day, do something just for you.
“It’s going to be unique for everybody, but do something that you know will lift your spirits,” says Dr. Ferguson. “This is not a cure for depression, but something that gives you a little lift and helps you feel better can make a difference.”
It can also be helpful to journal, even if you’re not ready to jot down all of your thoughts at first.
“You can draw or write down your favorite song lyrics to get started if you’re having trouble tapping into how you’re feeling,” says Solodovnik. “Writing down one thing you’re grateful for every day can also really change the way you see your surroundings.”
5. Seek immediate help if you have intrusive or harmful thoughts
“If you find you’re having intrusive, self-aggressive, or suicidal thoughts like ‘I’m just taking up space’ or ‘Nobody would miss me if I was gone,’ then don’t even wait five days,” says Dr. Ferguson. “That’s a time to call a suicide hotline immediately to let someone know you need immediate help.”
Doing so does not mean you’re unable to cope or that you’re weak.
“Many people are feeling this way right now, and it’s not because something is wrong with you — it’s because things are wrong in the world,” says Dr. Ferguson. “It takes a lot of strength and courage to ask for help, but help is there.”
Get Mental Health Support
We understand how difficult it can be to cope during these uncertain times, especially when you are living with chronic illness. It is important to talk to someone who can help. You should contact your primary care physician or your insurance provider to learn about the supportive resources that are available to you. Here are other mental health resources for your reference:
- To find local support groups and services, you can call 1-800-950-NAMI (6264) or email firstname.lastname@example.org. The National Alliance on Mental Illness HelpLine can be reached Monday through Friday, 10 AM to 6 PM ET.
- For a counselor or therapist in your area, view the resources page at Mental Health America: Finding Therapy.
- Crisis Text Line (free 24/7 support via text): Text HOME to 741741
- The Friendship Line from the Institute on Aging (toll-free 24/7 support for people ages 60 or over and adults living with disabilities): 1-800-971-0016
- LGBT National Hotline (free, confidential support for the lesbian, gay, bisexual, transgender, queer, and questioning community): 1-888-843-4564
- If your mental health concern is an emergency for you or someone else, you should call 911.
- If you are having suicidal thoughts or have or are thinking of hurting yourself, you should call the National Suicide Prevention Lifeline’s 24-hour toll-free crisis hotline, 1-800-273-TALK (8255).
Get Free Coronavirus Support for Chronic Illness Patients
Join the Global Healthy Living Foundation’s free COVID-19 Support Program for chronic illness patients and their families. We will be providing updated information, community support, and other resources tailored specifically to your health and safety. Join now.
Acceptance and Commitment Therapy. Psychology Today. Accessed December 31, 2020. https://www.psychologytoday.com/us/therapy-types/acceptance-and-commitment-therapy.
Chronic Illness and Depression. Cleveland Clinic. January 17, 2017. https://my.clevelandclinic.org/health/articles/9288-chronic-illness-and-depression.
Cognitive behavioral therapy. Mayo Clinic. March 16, 2019. https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610.
Dialectical Behavioral Therapy (DBT). Columbia University Irving Medical Center. Accessed December 31, 2020. https://www.columbiadoctors.org/treatment/dialectical-behavioral-therapy-dbt.
How Does Coronavirus Affect the Brain? Johns Hopkins Medicine. June 4, 2020. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/how-does-coronavirus-affect-the-brain.
Interview with Jason Levine, PhD, a licensed clinical psychologist based in West Los Angeles
Interview with Laurie Ferguson, PhD, a clinical psychologist and Director of Education Development at the Global Healthy Living Foundation
Interview with Rebecca Solodovnik, MHC-I, a mental health counselor at NYC Counseling
KFF Health Tracking Poll – December 2020: COVID-19 and Biden’s Health Care Agenda. Kaiser Family Foundation. December 18, 2020. https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-december-2020.
KFF Health Tracking Poll – July 2020. Kaiser Family Foundation. July 27, 2020. https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-july-2020.
Matcham F, et al. The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology. September 3, 2013. doi: https://doi.org/10.1093/rheumatology/ket169.
Mindfulness exercises. Mayo Clinic. September 15, 2020. https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/mindfulness-exercises/art-20046356.
Sambamoorthi U, et al. Healthcare burden of depression in adults with arthritis. Expert Review of Pharmacoeconomics & Outcomes Research. January 20, 2017. doi: https://doi.org/10.1080/14737167.2017.1281744.
Seasonal affective disorder. Mayo Clinic. October 25, 2017. https://www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/symptoms-causes/syc-20364651.
Seasonal Affective Disorder: Using Light Therapy. Michigan Medicine. May 28, 2019. https://www.uofmhealth.org/health-library/ty6702.
Seasonal Depression. Cleveland Clinic. December 7, 2020. https://my.clevelandclinic.org/health/diseases/9293-seasonal-depression.
Selective serotonin reuptake inhibitors (SSRIs). Mayo Clinic. September 17, 2019. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825.
Taquet M, et al. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. The Lancet. November 9, 2020. doi: https://doi.org/10.1016/S2215-0366(20)30462-4.
The Arthritis-Mental Health Connection. Arthritis. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/arthritis/communications/features/arthritis-mental-health.htm.