Pressure to be merry places extra burden on depressed patients
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Depression seems to peak at the holidays, but it's a year-round condition for many


Date published: 12/26/2004


IT SEEMS A GOOD TIME to write about depression.

"You Grinch,"€? I hear you all cry. "Trying to deflate our happy holiday spirit."

Depression is a fascinating subject to which I am not a total stranger myself, and I have had it in mind to write a piece about it for a long time.

This time of year, it seems to come to the fore, but it was a depressed patient who prompted me to finally do it. He told me his counselor had advised him to come twice a week instead of once "because it's the holiday season."

This was a guy going through a divorce and feeling the strain of all those extra chores involved with Christmas and the holidays--getting out cards, fretting over finances, wrapping presents, and biggest of all, shopping, shopping, shopping (and wondering, will the gift we are getting for so-and-so be what they really want and be as expensive as the one they are getting for us?).

In addition, any divorced or separated parent has the added problem of figuring out how to make it OK for the kids, and whose house they will be at, etc.

This patient also was suffering from that special burden of the holiday season: feeling especially bad because he was not merry and full of goodwill to mankind as he's meant to be over the holidays--as the Norman Rockwell paintings and movies on TV and cheesy Christmas music that pervades every public place this time of year would have us believe.

Not depressed?
This guy had many of the classic symptoms of depression, but he denied that he was depressed, primarily because of a lack of education and a pervasive notion in our society that depression is an unacceptable illness.

Harrison's authoritative "Principals of Internal Medicine" lists the symptoms of depression as depressed mood, weight change, insomnia, psychomotor retardation or agitation, fatigue, worthlessness, anhedonia (more on that later) poor cognition and recurrent thoughts of death or, in the most extreme, suicidal plans.

But patients don't know what the textbook says, nor do they admit to the symptoms until you translate them. They don't know they have anhedonia (literally, lack of ability to have pleasure).

They do agree that they can't get motivated, and that they've got the "blahs." This guy told me he used to be a big NASCAR fan, but now he just couldn't care less. He had anhedonia.

The worthlessness and poor cognition that accompany depression cause people to feel bad about themselves, like they can never make the right decision about anything. They think they never look good. They feel guilty about everything. And they have trouble concentrating, which makes decision-making very hard.

Depressed patients feel overwhelmed all the time--at home with the family, or at work. They describe it as juggling and having too many plates in the air.

Two prominent symptoms seem to be missing from Harrison's list, which I find people do often readily admit to. One is a lack of interest in sex, or loss of libido.

The other is irritability. They're on a short fuse and are grouchy, a symptom that is often noted more by family members and workmates than the patient himself.

It's intriguing to me the multiplicity of ways in which these basic symptoms manifest. I have been keeping a list of various bizarre and unusual manifestations of depression. (Send me yours!)

Two of my favorites are the patient who couldn't sit on the bleachers at a child's sporting event but had to pace up and down the sideline--until going on antidepressants. The other was the man who didn't whistle anymore.

To let you in on a little secret, I have suffered bouts of depression myself--nothing exotic like these patients. Mainly just crabbiness and persnicketiness. But more about that, and the discomfort of admitting it, in the second part of my two-part series on depression next month.

The dark days
Many patients are comforted by an understanding of what happens to their brain chemistry in depression, and are helped by antidepressant medicines--which is one, but not the only, form of treatment. More on that next month also.

One slightly alternative treatment that is relevant to a discussion of depression in the holiday season is use of a light box.

This is the way you treat Seasonal Affective Disorder, which is a form of depression brought on by the lack of exposure to sunlight that we incur during the short days of winter, and when we spend a lot of time indoors.

You could, of course, just take a trip to the Caribbean and soak up a little sunlight there, which would also get you away from the hurly- burly life that has very probably contributed to your depression. It is my observation that burnout and depression are very often more or less the same thing.

In all seriousness, getting away from some of the stresses and getting at least 20 minutes of aerobic exercise three times a week will help treat depression. So will learning techniques that revitalize your weary brain, things like meditation, biofeedback and yoga, for example.

I certainly think the Holiday Affective Disorder that we tend to suffer from is a burnout thing, with everyone spazzing out over all that they've got to get done--in addition to their usual over-busy everyday lives.

Interestingly, though, a literature search revealed no studies that have actually shown a documented increase in depression over the holiday season. One showed that suicide specifically was relatively low at this time, and peaked in May--so this is not just a disease exclusive to the dizzy, fizzy festive season.

Yet everyone believes depression increases at this time of year, and there are numerous articles on coping strategies, such as one telling you to schedule time for yourself, eat a healthy diet, find a support network and make organization the key, which is all good advice.

Maybe organization is the key, so that the holiday chores don't all pile up and the approach of this merry season doesn't seem like a tornado bearing down.

Maybe, I can get to be like those insufferable people who smugly tell you in September that they've finished all their Christmas shopping.

One mental-health tradition that my family has always upheld is vigorous walking, either on Christmas Day to shake down the Christmas dinner, or a tradition that I have adopted here is to have a country "Winter Walk" on Boxing Day (the day after Christmas when, traditionally, the hard-working servants get a little mental-health break with the day off and their Christmas "box," or gift).

Fresh air and exercise. It's frightfully healthy and invigorating, and there's a dose of chemical antidepressant to reward you afterward in the form of a spot of tea and hot whiskey.

Care to join us?

DR. PATRICK NEUSTATTER can be reached at [email=pneustatter@prattmed.com.]pneustatter@prattmed.com.[/email]

Date published: 12/26/2004