Blue Christmas

Like the BMJ(which is what we have to call the British Medical Journal these days) with their Christmas edition, I usually try to write about the lighter aspects of medicine and the holidays – like the pathologies of Christmas with overbearing sentimentality (from Christmas movies and cheesy music), gluttony, induced poverty (from buying presents), infidelity (at the office Christmas party) and the like.  

You're Expected to Be Jolly

But for those of you who find the whole holiday thing a little overwhelming, I thought I would share a column I wrote a while back about depression at this time of year.

“You curmudgeon. You Grinch” I hear you all cry. “Trying to deflate our happy holiday mood.” 

It was the depressed patient who told me his councilor had advised him to come twice a week instead of once “because it’s the holiday season” that prompted me to write this.

The Unhappy Holidays 

Depression, which has the peculiarity of being both a symptom and a diagnosis, is a subject to which I am not a total stranger myself. There are many aspects of this emotionally laden diagnosis that make it warrant some discussion. 

This patient was going through a divorce. He was feeling the strain of all those extra chores many of us have to deal with at Christmas and the holidays  and especially divorced parents (which I also have experience of). Such parents not only have to deal single handedly with with getting out cards, putting up the decorations, wrapping presents, and all that shopping shopping shopping  (and the worry of will the gift you give to whoever be as expensive as the one you get from them?) but in addition you have to make anguished arrangements for who is going to have the kids when. 

 In addition this guy was feeling especially bad because he was not merry and full of goodwill to mankind like he’s meant to be over the holidays  - as the Norman Rockwell pictures and the movies on TV and the ghastly Christmas music (that pervades every public place at this time of year) would have us believe.

“I’m not depressed”

The other point was that though he had many of the classic symptoms, but denied that he was depressed – primarily because of a lack of understanding. But combined with a pervasive notion in our society that depression is an unacceptable illness.

Harrison’s authoritative Principals of Internal Medicinelists the symptoms of depression as depressed mood, anhedonia, weight change, insomnia, psychomotor retardation or agitation, fatigue, worthlessness, poor cognition and recurrent thoughts of death – or in the most extreme plans for suicide.

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 agree that they “can’t get motivated” and they’ve “got the blahs”, and this guy told me he used to be a big NASCAR fan, now he just couldn’t care. He had anhedonia. 

The “worthlessness” and “poor cognition” are other slightly obscure symptoms who’s human side is that it causes people to feel bad about themselves. And they can never make a decision that they feel comfortable is the right one. They feel like they never look good, they feel guilty about everything, and they have trouble concentrating which makes decision making even harder. They feel overwhelmed all the time at home with the family or at work. People describe it like having too many plates in the air.

Anxiety is a separate psychopathology in strict medical compartmentalization of the DSM, but many people have a lot of anxiety inextricably intertwined with their depression.

 Two prominent symptoms that seem to be missing from Harrison’s list (I’ll have to write to him) which I find people often readily admit to are, irritability – they’re on a short fuse and are grouchy (a symptom that tends to be noted by family members and workmates rather than the patient themselves – and which makes people spurn them as a bear, rather than invoking sympathy). The other is lack of interest in sex – loss of libido.

It intrigues me the multiplicity of ways in which these basic symptoms manifest, and I have been keeping a list of various bizarre manifestations of depression that the patients tell me about (send me yours!). Two of my favorites are the woman who couldn’t sit on the bleachers at her son’s soccer game but had to pace up and down the side line – until she was put on antidepressants. The other was the man who didn’t whistle anymore.

In full “confession” mode, let me tell you I have had bouts of depression and have been on antidepressants – a revelation I feel uncomfortable telling the world. Though I wouldn’t feel bad telling you I have allergies and take allergy medicines. I have heartburn and take Pepcid. I have arthritis and take Motrin. So why is a chemical imbalance above the neck so unacceptable?

A Chemical Imbalance and The Depression May Be Good For You

In the final common analysis, whether you are depressed because your spouse has run off with another lover, or you got fired, or your mum died or, as so often, there is no discernable reason for it, the final common pathway is a chemical imbalance. Your brain doesn’t have enough serotonin, and bingo, you’re depressed. Actually there are other neurotransmitters involved like nor-epinephrine and dopamine, but serotonin is the main one, and the basic antidepressants like Prozac, Zoloft, Paxil, Selexa, Lexpro are pure “selective serotonin re-uptake inhibitors (SSRI’s) – that is they stop the serotonin from being broken down so there’s more available to stimulate your brain cells and keep you perky.

But I guess I’m like a lot of my patients in feeling a bit uncomfortable to admitting to a “psychiatric disease”. My personal manifestation was constantly feeling burned out, neck muscles stiff and painful, never feeling I made the right decision about patient management or is it OK for the kids to go to this or that persons sleep over. Also not getting joy out of former delights like putzing in my garden. 

And most of all being a bear in the office and getting inordinately upset about stupid little things that really don’t matter when you step back – and figuring I’d better get on some medicines before I drove all the (long suffering) staff away.

  I have to say, I did not feel good about taking medicine to re-arrange my brain chemistry – as do many of my patients – though this is changing it seems thanks to direct to consumer advertising.

 There are lots of ad’s for antidepressant medicines in this day and age, and many people come for-armed with the idea they want medicines - and what one they want.

As a cynic, I liked the cartoon they had on the bulletin bored on 4 South at the hospital where a woman is complaining to the doctor “The medicines not working right. I’m not as happy as the people in the Paxil advertisement”.

As with so many illnesses – or aspects of our lives – we are inclined to medicate away any pain or discomfiture. But there are different views. In his book Care of the Soul, Thomas Moore has a whole chapter on ‘Gifts of Depression’ in which he expounds the idea that depression is a necessary evil we must all go through. “The soul presents itself in a variety of colors, including all shades of gray blue and black. To care for the soul we must observe the full range of all its colorings and resist the temptation to approve only of white red and orange. ”

The melancholy mood of depression is associated with an expression of our soul that is as valid as the expression of bright, light and cheery side, and is associated with maturation, gaining of wisdom and retrospection he says.

Sometimes it’s hard to persuade people a little bit of pain is good for them – and maybe I’m as disinclined to suffer as the next. Certainly depression can be bad enough to make your life very difficult and suffer a lot - sometimes to the point where people can’t get out of bed, and antidepressants can have dramatic effects in getting people motivated and moving again.

Matching You To Your Medicine

If you do resort to antidepressants, the choice of which, tends to be something of an individual one. You have to match the character of the medicine to your own, and this requires one on one consultation to take into account factors like do you have a lot of anxiety as well; are you very lethargic, or rather very hyper; do you have sleep problems; are you very sensitive to weight gain or sexual dysfunction etc.

One specific treatment that is relevant to a discussion of depression around the winter holiday season is use of a light box. This is the way you treat Seasonal Affective Disorder (SAD), which is a form of depression brought on by the lack of exposure to daylight/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 day/sunlight there, which would also get you away from the hurly burly of life that has very probably contributed to your depression – for it is my belief/observation that burnout and depression are very often more or less the same thing.

In all seriousness, getting away from some of the stresses if you can, partly by learning techniques that will revitalize your weary brain – like meditation, biofeedback and yoga for example – and exercising (at least twenty minutes of aerobic exercise three times a week) will all help treat depression.

I certainly think the “Holiday Affective Disorder” is a burn out thing, with everyone spazzing out over all that they’ve got to get done – in addition to their usually over-busy everyday lives. Though interestingly 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.

What is interesting is that everyone believesthat depression is increased at this time of year and there are numerous articles on coping strategies. “Schedule time for Yourself”, “Remember Healthy Diet”, “Find your Support Network”, “Organization is the Key”, “Return to the Simple” are suggestions in one article for example - which is all good advice.


Maybe organization is the key, so that it doesn’t all pile up and the approach of this happy holiday 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. 

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