Sunlight Is the Best Medicine

Pioneering nurse Florence Nightingale was rigorous not only about kindness and cleanliness—she maintained meticulous statistical records about her patients to determine the most effective treatment practices.

Florence Nightingale

Source: Wikimedia

In addition to encouraging good ventilation, promoting adequate sleep, providing a nutritious diet, and allowing plants and flowers in the sickroom (she knew that they provide oxygen and consume carbon dioxide, as well as provide a pleasant focus), Nightingale was an enthusiastic proponent of allowing as much natural light into the patient’s room as possible.

As she wrote in Notes on Nursing, “It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light…And that it is not only light but direct sun-light they want.” She knew that her patients in rooms facing east recovered more quickly than those in rooms facing other directions—or in windowless rooms. She observed her patients turning their faces toward light and compared them to plants following the sun in its course across the sky. We cannot be sure whether this light acted as a mood and energy enhancer in the hospital room or also contributed to ridding of her patients’ infections or other disease processes. But her realization was perspicacious and foretold of light therapies, in various forms, that continue in active development.

National Jewish Hospital

Source: wikipedia

Similarly, before the development of antibiotic therapy for tuberculosis, sanatoriums addressed the worldwide pandemic with sunlight. Doctors noted that patients who lay in the morning sun gained more weight and went home sooner. This became standard practice around the world:

  • In 1903 Swiss doctor Auguste Rollier opened his “sunlight clinic,” which featured an enormous solarium on the roof and developed a slow, careful tanning process for new or especially feeble patients. Here, the ultraviolet (UV) component in sunlight, acting on the skin—now understood as carcinogenic in high doses—was the presumed mode of action, although the patients may also have benefitted from the mood and energy boosts of light to the eyes.
  • Deep in a Finnish forest, in 1929 architect Alvar Aalto built a sanatorium that prioritized access to natural light, enabling patients to benefit from the sun while resting comfortably in their rooms. Light through the windows would have substantially reduced UV exposure, and the benefit of such filtered light to the eyes seems likely to have involved the mood-energy effect.
  • In the early years of the 20th century, my great-grandparents ran a tuberculosis sanatorium in the beautiful town of Otwock, Poland. The air was clear, the climate was sunny, and the patients—when they weren’t eating one of their eight daily meals—spent their time lying quietly in the sun, well bundled up in autumn and winter. Bundling up outdoors in fall and winter, when UV levels from skylight are lower than in spring and summer, again imputing mood-energy enhancement mediated by visible light.

What Nightingale observed more than a century ago, modern science has now proven. Sunlight reaching the eyes can reset a person’s circadian rhythms, enabling a healthier sleep-wake cycle and better healing. And it can be deployed strategically to treat mood disorders in particular. Don’t take my word for it—here’s some more recent evidence:

  • Pioneering chronotherapist Francesco Benedetti and his colleagues found that patients suffering from bipolar depression who were placed in rooms with an eastern exposure with earlier morning sunlight recovered almost four days faster than patients whose rooms had a western exposure. Similarly, another study found that patients admitted to two hospitals for depression—one with sunny rooms, one with darker rooms—stayed approximately three days less if they were in the sunnier rooms.
  • Benedetti also demonstrated that artificial sunshine from light therapy lamps can be an effective, non-invasive, and safe intervention for bipolar depression, which can be difficult to treat with antidepressants, and their hit-or-miss effectiveness for individual patients. The risk of triggering a manic or mixed episode of the disorder was very low, certainly no higher than with the drug therapies.
  • A 2013 study of patients with cystic fibrosis and co-morbid depression suggested that exposure to light significantly improved patients’ chance of depression remission.
  • A review of hospital admissions in Egypt, a country with year-round sunshine and a fairly stable climate, showed more admissions for depression in December, and more admissions for mania in June. In contrast, schizophrenia admissions did not vary by season. This is consistent with a large body of research that suggests that bipolar disorder is a circadian rhythm disorder.

A modern heir to Rollier and Aalto is Dr. Richard Hobday, who is what the British call a “chartered engineer.” I might not recognize that term, but I’m impressed by his research and practice. Hobday’s book, The Light Revolution: Health, Architecture and the Sun, delves into the history of how sunlight has been used to alleviate conditions ranging from rickets to heart disease. He advocates “5 Points of Solar Architecture for Health”:

  1. Orient the building for sanitation and sunbathing.
  2. Position the rooms for sunlight therapy and disinfection.
  3. Put windows in more than one wall to let the sun in at different times of the day or year.
  4. Ventilate naturally.
  5. Underfloor heating.

As I prepare for a surgery in the spring (once the winter burden of SAD has passed), I’m definitely going to ask the hospital if I can be placed in a room with an eastern exposure. And after I go home, I’ll be sure to spend plenty of my recovery time relaxing (well-sunscreened) in Central Park, soaking up the healing sunlight.

Abigail Strubel

Source: Abigail Strubel

Abigail Strubel, MA, LCSW, CASAC is a Columbia-educated clinical social worker and ​certified alcohol and substance abuse counselor. She uses light therapy to cope with her seasonal affective disorder, and also manages chronic insomnia through acupressure and good sleep hygiene. She has worked with formerly homeless adults, ex-offenders on parole, recovering heroin users, and other interesting populations. Abigail’s posts at the Center for Environmental Therapeutics fuse humor with practical insights about mood, sleep, and alertness.




Terman, M., & McMahan, I. (2013) Reset Your Inner Clock: The Drug-Free Way to Your Best Ever Sleep, Mood, and Energy. New York: Avery/Penguin Random House.


A Tale of Two Sleepers

How a champion sleeper and an insomniac learned to synchronize their sleep schedules.

A Tale of Two Sleepers

It was the best of sleep, it was the worst of sleep—in the same apartment and the same bed. Abigail’s co-worker Clara and her partner, Javier, grew up in the same neighborhood and fell in love after college. It wasn’t until they moved in together that they discovered they had radically different sleep behaviors and attitudes. Could a sleep pattern established during childhood be changed to eliminate adult insomnia? Spoiler alert: unlike Dickens’ tale, this story has a happy ending.

Clara is a policy analyst at the city agency where I work. She’s known her partner, Javier—who goes by “Javi”—since childhood. “We grew up in the same neighborhood in Queens, and we were in the same after-school program for years as kids,” says Clara. “We were friends in college, and eventually we started dating.”

Falling in love with the boy next door sounds almost like a fairy tale. Reality hit after they moved in together. “Javi liked to stay up very late, and had a terrible time getting up in the morning,” remembers Clara, who usually goes to sleep by 11:30 pm. “Sometimes he was up because he couldn’t fall asleep, and sometimes he’d fall asleep but wake up a few hours later and not be able to fall back asleep.” (As a fellow sufferer of terminal insomnia, I could definitely relate.)

Javi likes reading in bed, which Clara appreciates. “Sometimes he reads to me and I fall asleep,” she sighs. “It’s kind of like when my mother read to me when I was a child. But she did voices; when she read the Fudge books by Judy Blume, she’d do her ‘fudgey’ voice.” Javi reads Clara the serious literature he enjoys, from a stack of scholarly biographies and histories on his side of the bed.

How does she fall asleep so quickly? wonders Javi

“On my side, I have four or five books that I’ve never finished,” admits Clara. “I get into bed and read a few pages, and then I fall asleep.”

Clara believes her parents successfully trained her to sleep well.

“I remember climbing up onto my dad’s recliner chair so I could nap on his chest,” recalls Clara. “He started napping with me when I was a tiny infant, and it must have continued until I was three or four.” As Clara grew, she continued to associate sleep with a sense of “happy coziness,” she reminisces with a contented, faraway look. “I was a shy kid, kind of a loner, so I was never afraid of being alone, and since I loved sleeping, I never minded going to bed.”

baby and dad sleeping

Clara’s mother reinforced good sleep hygiene with strict bedtimes that increased incrementally as Clara grew up: 7 pm at age 7, 7:30 pm at age 8, 8 pm at age 9, and so on until Clara was a teenager.

“Even as a teenager, I still used my bed just for sleep,” she says. “I remember being told that if you do your homework on your bed you’ll associate your bed with work, so I did my homework on the floor of my bedroom or the dining room table. In college, too—I never studied on my bed. The only time I read in bed is Saturday morning; it’s a nice, slow way to wake up.”

And Clara developed a special technique to help herself on nights when sleep eluded her. “When I was very small, I developed this image in my head of a bookshelf with rows of books in order—like the ‘Harry Potter’ or ‘Baby-Sitters’ Club’ series. Each book had its own topic, like playing with friends, and I’d think about that topic as I drifted off. Sometimes now if I have something on my mind, like a recurring thought, I ask Javi for a topic. He suggests things like dinosaurs” (which didn’t work) “or going to a Mets game” (which had happy childhood associations and helped soothe Clara to sleep).

Clara's Sleep Library

Clara’s Sleep Library













The good sleep hygiene instilled by her parents and refined by Clara herself enables her to wake up refreshed and happy almost every morning. “I still love napping, too,” she confides. “On the weekends I’ll nap.”

Javi’s story was quite different. “Javi’s parents like to stay up late. If my parents stay up late, they end up falling asleep in front of the TV. But Javi’s mom—she didn’t like going to sleep. Javi thinks she influenced how he feels about sleep—like going to bed means you’re going to miss out on something. We blame our moms for everything, don’t we?”

Regardless of fault, Javi couldn’t understand how easily and quickly Clara could go to bed and fall asleep. “He would stay up if he didn’t feel physically tired—he’d say, ‘I didn’t work out today’ or ‘I slept late today.’ He didn’t think of sleep as a habit—more of a response to activity (or lack of activity).”

Javi tried reading in bed, but found that even the driest of academic tomes couldn’t lull him. He switched to popular fiction like spy novels or detective procedurals. When those failed, he turned to silly books like collections of “Garfield” cartoons. Still, he struggled to fall or stay asleep—and struggled even more the next morning to wake up.

Napping on Clara’s father’s chest wasn’t really an option, even though both sets of parents still live in Queens. So Javi did the next best thing: he adopted Clara’s sleep schedule.

“He made a New Year’s resolution to try to sleep better,” says Clara. “Now during the week he goes to sleep when I do, whether he feels tired or not. I usually fall asleep faster than he does, but he’s falling asleep faster than he used to and not waking up as much.” Javi still stays up late on weekends—for optimal sleep hygiene, it’s recommended that you get up and go to bed at the same time every day of the week. But his sleep pattern during the week has become much more regular and restful.

A Tale of Two Sleepers

Credit: Vera Kratochvil/public domain

It is a far, far better sleep that he sleeps, than than he has ever slept. It is a far, far better rest that he goes to than he has ever known.

Abigail Strubel


Traveling Light: Why I brought my light to Chicago

Our intrepid Abigail Strubel, having experienced an array of disappointments with one treatment or another — admittedly sometimes with temporary relief — hones in on light therapy, to which she gets seriously attached. —Michael Terman

In November of 2014, my cousin’s daughter celebrated her bat mitzvah in Chicago. I live in Manhattan, but I was eager to celebrate with her and my family. However, I was anxious on one count: with the onset of Standard Time in November, I start using a light box to combat my Seasonal Affective Disorder (SAD). The box isn’t heavy, but neither is it small. So I debated whether to pack it, or chance the weekend without it.

The Monday after the celebration, I was slated to start a new job as clinical supervisor in a busy substance abuse clinic. I knew I had to hit the ground running; I couldn’t bring my B game on the very first day. So when I packed my suitcase, I included several fancy outfits, my toothbrush, makeup, and my light box, wrapped in several layers of clothing.



To Be or Not to Be Without a Light Box

I called the airline to ask about taking the light box through security; I didn’t want it confiscated, and emphasized that I needed it for medical reasons. I was advised to take the light box out, and put it in a separate bin for screening, when I got to the airport.

None of the Transportation Security Administration (TSA) agents batted an eye as I unbundled it from its swaddling and placed it carefully in a bin, which sailed through the X-ray on the conveyer belt just ahead of my suitcase, purse, and shoes. Relieved, I retrieved all my belongings and went to the gate.

At home, I’d been using the light box from 6:45 to 7:30 a.m. So at approximately 6:45 a.m., a few hours before my flight was due to take off, I plugged the light into an electrical outlet near one of the seats at the gate, placing a book in the next seat.

When you use a light box for SAD, you don’t look directly into the light itself; you look at a piece of paper or something pale near the box, and the light reflects into your eyes. First I tried sitting two seats away and putting a book on the seat between me and the box, but I was too far away; optimal distance between you and the source of light is 12 inches. Sitting on the seat next to the box with the book in my lap, I had to hunch my neck uncomfortably. Ultimately, I sat on the floor, put the book on the seat next to the light box, and read the book.



The Strange Woman Sitting on the Floor

The usually good thing about New York is that most people don’t notice what’s going on around them if they’re not personally involved. Glancing up furtively from time to time, I never noticed anyone watching the strange woman sitting on the floor near a row of empty seats and a peculiar lamp. After 45 minutes – the time my doctor and I have determined is necessary for me – I unplugged the lamp and waited a few minutes for it to cool before rebundling it in clothing for the flight.

In Chicago, I shared a hotel room with my oldest niece, 17, who was intrigued by the light box. I set it up on the desk, explained what it does, and showed her how I use it. Although she said she wanted to watch me use it, like most teenagers she’s not much of a morning person, so I used it unobserved, early on Saturday and Sunday mornings.

Good Luck, and a Happy Ending

Traveling with the light box isn’t convenient, but for those of us with SAD, it might be necessary. I was happy that no TSA inspector took or broke it, and it survived the journey as well as I did. That Monday I faced my first day on the new job confidently, energy and concentration intact.

Abigail Strubel

Abigail Strubel

ABIGAIL STRUBEL is a Columbia-educated clinical social worker and certified alcohol and substance abuse counselor who uses light therapy to cope with her annual seasonal affective disorder, and also manages chronic insomnia through acupressure and good sleep hygiene. She has worked with formerly homeless adults, ex-offenders on parole, recovering heroin users, and other interesting populations. Her approach to wellness is a fusion of all compatible treatments—alternative or not—that make people feel better while also objectively reducing medical problems.


Sneaky SAD: How Seasonal Affective Disorder sneaked up on me, symptom by symptom.

Abigail gets fooled. The fall of 2015 was the warmest and brightest on record in New York, and winter depression seemed a distant thought.  As I remarked in a New York Times interview, though, “The people who have benefited until now are going to crash, and they will do it very quickly.” It did turn cold and dark in January, and, yes, people crashed … but not as fast as crash implies.  Before the depression hits, you’re noticing a parade of symptoms that culminate in the crash.  Below, self-observant Abigail writes the textbook case report. —Michael Terman

In early November 2015, I set up my light box and waited for SAD to strike. I even took the AutoMEQ self-assessment on to determine the optimal time to use it. But strangely, I was only hit with one symptom, terminal insomnia — which isn’t even a typical symptom of SAD, but which plagues me after every autumnal time change.

After trying various natural remedies, in December I caved and began taking a mild sleep aid prescribed by my doctor. After few weeks of solid sleep, I skipped the pill one evening and noticed that I still slept through the night. “Great,” I thought. “This year I’m giving SAD a pass!”

Unfortunately, SAD snuck up on me, symptom by symptom, until I could no longer ignore it.



Lack of Energy

In January 2016 — just last month! — I started noticing that I was having trouble getting up in the morning, even though I was sleeping through the night. This was puzzling, since I was still brimming with enthusiasm for the wonderful job I started in November. I expected to spring out of bed when the alarm rang, not hit the snooze button. I wasn’t going to bed late, so I was surprised to feel so tired after a full night’s sleep.

I added a few cups of green tea throughout the day to my usual two cups of coffee in the morning, and felt slightly more alert. I also stopped taking my nightly dose of melatonin, since its overall effects are sedating. That helped, too—but only briefly. Soon I found myself not only dragging myself out of bed, but almost dozing through the afternoons.

At first I attributed some of my lethargy to the turkey sandwich I frequently order for lunch, but I also felt sleepy without any extra tryptophan (the amino acid in turkey that is theorized to induce sleepiness).

I tried to brainstorm reasons for my listlessness. At my last check-up, my doctor drew blood for lab work and later informed me that I was slightly anemic.  He didn’t sound concerned or order more tests, so I more or less shrugged it off.

“How anemic am I?” I wondered. “Should I take iron?”

But my nail beds are a healthy pink — when you’re anemic, they pale to a bluish-white — and I wasn’t fainting or having nosebleeds, other typical anemia symptoms. I was just… really, really tired most of the time.

Before I went to the drugstore to stock up on iron supplements, another symptom hit and distracted me.



Carbohydrate Cravings

Sitting at my desk one January morning, I was overwhelmed with a craving for cake. Something dense, sweet, floury that you could sink your teeth into. Reviewing spreadsheets or typing up a presentation, my mind would wander, fantasizing about the enormous muffins I used to buy at a job I held more than 10 years ago. The muffins were so big, they were actually difficult to bite into; eating them wasn’t pretty, but it was tremendously satisfying.

I hated that job, but buying a hot cup of coffee and an enormous banana-walnut or cranberry muffin made going to work a bit sweeter. I hadn’t thought about those muffins in more than 10 years—yet they became an almost daily fantasy. I’ve always had a sweet tooth, but this craving had the force of a powerful instinct. Sleep, breathe, eat muffins.

I began buying muffins on my lunch break; after a healthy bowl of soup or turkey sandwich, I’d dive into a muffin and a big cup of coffee (the green tea wasn’t keeping me alert enough through the afternoon, and I didn’t want to fall asleep in front of the people I work with).

These were smaller muffins, though, and I never felt quite satisfied. If I skipped the muffin, later I’d find myself daydreaming about demolishing cake like a lion who’s brought down an antelope.

The annoying thing about cravings is that satisfying them only leads to stronger cravings. No matter how many muffins I brutalized, I still wanted more and more. Refined flour is low in fiber, so while a muffin might fill you temporarily, the satisfaction doesn’t last.

More importantly, too much sugar is bad for your teeth, weight, and mood. Although sugar crashes aren’t as drastic as cocaine withdrawal, they’re still perceptibly disruptive to your emotional balance. But I don’t think sugar was responsible for the final SAD symptom.


Source: Sad/ The Most Important News, public domain

Source: Sad/ The Most Important News, public domain

Although I’m a bit shy, I’ve made a real effort to be outgoing at work. I say “good morning” and “hello” to everyone, whether or not I know them. (In my defense, it’s a very large agency.)

This might seem obvious to a lot of you, but for me it took some effort. The rewards, however, were tremendous. Smiling is a natural mood elevator, a bit of folk wisdom that’s been born out by research. Smiling at so many people every day was making me feel more cheerful.

But gradually, without realizing, I stopped smiling and greeting my co-workers as I passed them in the corridors. I felt awkward and uncomfortable; I couldn’t meet their eyes.

Social withdrawal can be a sign of depression.

Then one morning I woke up and felt jangly. I couldn’t seem to get up, make coffee, get dressed. I couldn’t face the thought of going to work, sitting through meetings, reviewing case notes and developing training materials. Normally I breeze through those tasks on autopilot; that morning, deciding what color tights to wear was overwhelming. Anxiety and difficulty concentrating: two more signs of depression.

What could be wrong? I wondered. I love this job. I like almost all of my co-workers, and I’m comfortable with the population of clients we serve. Why would I be anxious or muddled?

I have seasonal affective disorder (SAD). That’s what’s wrong. It just didn’t hit me all at once this season. Amazing how a condition you’ve had for years can still surprise you. I usually expect to feel depressed and lethargic in mid-November; this year, it took me longer, but I got there eventually.

The good news is, I have a light box and I know how to use it. Unfortunately, according to my self-assessment I needed to get up at 6:00 am to use it, but I’ll do whatever it takes to feel better. So I reset my alarm clock and started using the light box, initially 15 minutes and increasing the dose as needed. After about five days, it was easy to get out of bed and start my day. I didn’t worry about falling asleep during long afternoon meetings, and making eye contact and smiling at my co-workers was comfortable again.

The muffins of this city, however, are still in grave peril.

Abigail Strubel

ABIGAIL STRUBEL is a Columbia-educated clinical social worker and certified alcohol and substance abuse counselor who uses light therapy to cope with her annual seasonal affective disorder, and also manages chronic insomnia through acupressure and good sleep hygiene. She has worked with formerly homeless adults, ex-offenders on parole, recovering heroin users, and other interesting populations. Her approach to wellness is a fusion of all compatible treatments—alternative or not—that make people feel better while also objectively reducing medical problems.

Interminable Terminal Insomnia

When a clinician’s bag of tricks is no match for her early morning waking

One of my least favorite symptoms of seasonal affective disorder (SAD)―not saying I enjoy the low mood, decreased energy, and impaired concentration―is terminal insomnia.

Terminal insomnia is also known as “early morning waking.” It can take place anytime between 2 and 4 a.m., and it’s usually difficult to fall back asleep. It’s a well-known symptom of non-seasonal depression, but not so well known for SAD. If you’ve read any magazine story about SAD, you’ve no doubt gotten the impression that oversleeping is the problem―but certainly not for me.  Why should I be so different? Continue reading

Complicated Grief and the Inner Clock

Abigail headshot 2"

Abigail Strubel, MA, LCSW, CASAC,

When is poor sleep a sign of a broken heart?

One of my most poignant patient interactions in the methadone program where I used to work was with a 73-year old woman I’ll call Maria. She suffered from numerous health problems in addition to her heroin addiction, including obesity, diabetes, a bout with breast cancer in her 40s, high blood pressure and elevated cholesterol levels.

But when I met with Maria to discuss enrolling in a geriatric case management program to help her better handle her health issues, all she could talk about was her late daughter, Isabel. How beautiful Isabel had been, how young when she passed away, what a perfect companion she was, and how lost and lonely Maria felt without her.

“I don’t care if the cancer comes back,” she told me. “Without Isabel, my life is pointless. I just want her with me again. I miss her so much. It feels like she died just yesterday.”

In fact, Isabel had died more than 15 years prior to our conversation. Maria’s feelings were typical of someone experiencing complicated grief, which is defined as negative feelings related to a loss that persist for at least six months, and impair a person’s ability to cope with and enjoy life. One prominent symptom of complicated grief is sleep problems. Continue reading