Understanding Depression during the Holidays.

Introduction

Depression at the holidays seems to come up every year. The holidays are nostalgic and make us think of other holidays back to our childhood. We are reminded of the people, places, and things from the old days, and if they were good old days, feeling sad and missing those people, places, and things is inevitable. Feeling sad or shedding a tear is normal.

I like to remind my patients just to be where they are. If they’re happy, they’re happy. If they’re sad, they’re sad. Emotions are like the weather. There is good weather and bad weather like good feelings and bad feelings, but we cannot control either the weather or our feelings and trying to is useless.

Instead, we can say comforting words to ourselves, like “of course I feel sad, of course I feel angry, of course I’m disappointed.” “Given who I am, what my background is, and what my situation is, these feelings are not only justified, they’re inevitable. It’s like having the flu or dropping something heavy on my toe. All things being equal, I would prefer bad things and bad feelings never happened. They bring up painful memories from the past, but things are different now. I’m older, and I can make smart decisions so that things turn out as well as they can.”

Clinical Depression

The depression I described in the first paragraph of this piece, which typically lasts a few minutes or an hour or so and does not impact a person’s overall functioning is nearly universal and not a sign of emotional or mental problems. But unfortunately, people also experience clinical depression, which causes suffering and has potentially dangerous consequences.

People with clinical depression have low mood or difficulty enjoying the good things in life most of the day most days for at least two weeks. During their depression, they experience five of the following nine symptoms: low mood or hopelessness, sleeping too much or too little, appetite being too high or too low and so having significant weight gain or loss, low energy, poor concentration or inability to think clearly, difficulty enjoying life including sex, feeling exaggerated guilt or shame, excessive restless movement or being slowed down, or recurrent thoughts about or urges to commit suicide.

People with clinical depression are unable to sleep or eat normally, their ability to think is impaired, their relationships with people they are close with, and more casual acquaintances are damaged, and some cannot function well enough to work, go to school, or even care for themselves. They die early from suicide but also from cancer and heart disease. Depression is a dangerous illness.

Risk Factors

Personal or family history of depression, loss or threatened loss of a loved one (e.g., through death, divorce, or separation), social isolation, major life changes including happy ones, medical illness (diabetes, cancer, heart disease, Parkinson’s Disease, stroke), conflicts in relationships, or physical, emotional, or sexual abuse. Women are twice as likely to develop depression as men, who are more likely than women to abuse substances.

Kinds of Depression

There is a spreadsheet on this website comparing the typical symptoms of melancholic depression with atypical depression and medical illness.

Melancholic depression is a syndrome that used to affect people before effective treatment was widely available. It tends to occur in elderly people, who wake up in the middle of the night with dark thoughts, anxiety, and suicidal impulses. Delusions and hallucinations can occur. They lose their appetite, have terrible restlessness, and sleep little. And they are so consumed with their inner life they do not usually notice the outside world.

Atypical depression affects younger people, who have trouble falling asleep and typically sleep all day and overeat but remain sensitive to social cues. People with bipolar illness tend to develop atypical depression.

Those of us who live where the seasons change notice how the loss of sunlight in fall and winter affects us. People who develop seasonal depression are so affected by the change in light that they have low mood only in the months when there is less sunlight. Bright light, particularly in the predawn hour, seems to help depression in general and especially seasonal depression. People who live near the equator can develop depression with increased temperatures.

People are diagnosed with bipolar illness if they have had an episode of mania, a period of at least a week, most of the day's most days, of elevated, expansive, or irritable mood and abnormally high energy or goal-directed behavior, plus 3 (4 if only irritable) of the following: inflated self-esteem or big ideas; decreased need for sleep; more talkative than usual; thoughts going so fast you can’t keep up with them; distractible; doing more, restless, or unable to relax; or doing things likely to get you in trouble like spending too much, sexual indiscretions, or conflicts with the wrong people.

After having a baby, women (particularly women with a history of bipolar illness) are prone to developing what is known as postpartum depression. Postpartum depression typically starts abruptly, is severe, is complicated by delusions or hallucinations, and is accompanied by physical symptoms. Because of the danger to both the mother and the child posed by the depression and the risk of taking medication while breast-feeding, many people affected by postpartum depression choose electroconvulsive therapy (ECT), which is also fortunately effective in this condition.

Severe depression can be complicated by delusions or hallucinations. Such a condition, known as psychotic depression or depression with psychotic features poses a grave danger of suicide or other dangerous behavior and is resistant to antidepressant treatment.

I want to mention one final condition, known these days as persistent depressive disorder, in which a person has at least two depressive symptoms continuously for two years or more. Years ago, it was hoped that since people with persistent depressive disorder had fewer symptoms of depression than people with major depression, a lower dose of medication might work. It does not. Perhaps because of its persistence, if anything it needs a higher dose for if anything a longer period of treatment.

What is Depression?

There has been lots of research into psychiatric illness, and we have an amazing amount of knowledge. We have methods to diagnose mental illness, including depression, but we do not know what happens to a person’s body that they develop depression or any other mental condition. Here’s something I wrote for another of the articles which may appear on this website:

I imagine that psychiatry has the state of knowledge that the rest of medicine had about two centuries ago. Back then, I imagine that doctors gave people Foxglove (the plant from which the medication digitalis is derived) and might have told them “Take this, it’s good for the heart”. And sometimes it was, but the doctor did not know why or why not. These days, we give people Prozac and tell them “Take this, it’s good for depression”. And sometimes it is, but we do not know why or why not. Someone might answer that we know that Prozac increases serotonin, which it does, and serotonin most likely has something to do with depression, which it does, but several medications which increase serotonin do not seem to help with depression and there are effective antidepressants which do not affect serotonin, and so the connection between serotonin and depression is loose.

Treatment

Depression is an interesting condition to treat. Anxiety disorders are best treated with psychotherapy. Psychotic illnesses like schizophrenia and bipolar disorder are best treated with medication. Depression responds to both psychotherapy and medication. But the benefits of psychotherapy last long after the end of treatment and the benefit of medication stops when the medication stops. To my way of thinking, using psychotherapy first makes sense.

Treatments for depression and other psychiatric conditions are developed based on what has been noticed to be helpful in the past rather than what is known to be the underlying problem. Consequently, psychiatric treatments are not consistently effective and can require trying one after another or adding one medication on top of another.

A spreadsheet for antidepressants is available on this website.

Medications in What Order?

Doctors tend to say that antidepressants take 4 to 6 weeks to work. What they mean is that antidepressants may take 4 to 6 weeks to become fully effective. If an antidepressant is not helping at all after two or three days, it is most likely a poor choice for you, and if you were my patient, I would switch to a medication from a different class. If a medication is partially effective, I would add a medication from a different class. If you still have symptoms, I might add a third medication. The antipsychotics Abilify (aripiprazole) and Seroquel (quetiapine) are approved for treatment of depression and the mood stabilizer lithium carbonate is another consideration.

There are so many possibilities and so many combinations that trying all is virtually impossible, but sometimes the depression is so severe or the patient is suffering so much that going to something that likely works quickly is the priority. Electroconvulsive Therapy (ECT) is what I usually recommend. Ketamine probably works equally well, but because it is relatively new, I shy away from it. Transcranial Magnetic Stimulation (TMS) is probably going to be a good alternative, but its results so far have been somewhat disappointing.

Yet I have hardly ever found a patient whose depression I could not cure. I am puzzled that there is a fair amount of discussion in psychiatric journals about “Treatment Resistant Depression”. My patients do not seem to develop it, though finding the right treatment can take time.

How long should treatment continue? If you have no symptoms and no side effects, treatment for a first episode of depression might be six months. For someone with multiple episodes or chronic depression, it might make sense to continue the treatment indefinitely. I like the patient to make that decision with my advice.

Conclusion

There are many types of depression, but all can be treated, and the treatments are well tolerated and effective.

Created 12/3/22

Melancholic vs atypical depression vs medical illness.xlsx

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