Holiday Blues

For most people, November means it’s time to order the turkey, bring the ornaments down from the attic and joyfully anticipate the magic of the holidays. For some, however, November feels like that last, long walk to the gallows as they face the looming terror of the holidays.

"The more I tried to get into the spirit of the season, the more tense and anxious I got," recalls "Geraldine," a west suburban resident who recently recovered from years of chronic depression. "I really wanted to have the same kind of happy Christmas other people were having, but I just couldn’t handle the pressure. Just the thought of Christmas dinner with my family made my heart pound."

Not that depression is easy to handle the rest of the year. Clinical depression isn’t just feeling sad or apathetic, according to the National Alliance on Mental Illness (NAMI). It’s a disabling medical condition in which physical, mental and emotional dysfunctions combine to impair sufferers’ ability to experience emotions, focus on tasks or enjoy favorite activities like hobbies, sports — even eating and sex. Its victims frequently suffer from insomnia, chronic pain, irritability and pervasive hopelessness — and self-medicating by overindulging in alcohol, drugs or comfort foods only makes their situations worse.

"One in four Americans will experience a mental health issue in the next year, and depression/anxiety disorder is the most common issue," notes Anna Padron Sikora, associate vice president of Pillars mental health service in La Grange Park and a licensed clinical social worker. "Life is so stressful at some stages that it’s easy to become depressed without even realizing it until it gets out of control."

Area experts disagree on whether depression rates are rising in the western suburbs. "I’ve seen a 10 to 20 percent increase in the number of people who come to us for help with depression," says Sheri O’Brien, a licensed professional counselor at Tri-City Family Services in Geneva. "We’ve definitely seen more people come in since the 2008 economic collapse because so many people got laid off or lost their homes, then developed depression as a result."

But Dr. Greg Teas, a psychiatrist at Amita Health/Alexian Brothers Behavioral Health Hospital in Hoffman Estates, disagrees. He maintains that the rise in the number of patients seeking treatment is due primarily to increased public awareness of how serious depression can be, and consequently more people are seeking treatment.

"The numbers of persons identified in household surveys describing depression are largely the same over time," says Teas. "However, there may be more persons seeking treatment as they now have better access to some degree of insurance via the Affordable Care Act. Also, schools, both primary and secondary, are more concerned about suicide and are more aggressive at referring individuals to mental health professionals whenever a potential case of threatening behavior — often via social media to a friend — occurs. Primary care physicians are also becoming more proactive in diagnosing and treating depression."

NAMI’s local initiative to train Chicago-area primary care physicians and emergency room medical staff in depression diagnosis is helping more sufferers get the help they need, Sikora says. "We’re working with medical practitioners as well as community leaders to promote mental health first aid.

"Many people with severe depression go to the emergency room because their related anxiety produces the same symptoms that heart attack victims often experience, like rapid heartbeat, shortness of breath and chest tightness," explains Sikora. "Then they think they’re going crazy because their EKG shows that their heart is working normally. Now people at most of the hospitals in Cook and DuPage counties know to screen these people for depression."

An emergency room visit gave Geraldine the news that she had seasonal affective disorder, a serotonin deficiency that causes depression mostly during the winter, as well as chronic depression. 

"Years ago I was out grocery shopping in November when I became convinced I was having a heart attack, even though I had just turned 30," she says. "I went to the emergency room and described my symptoms to the nurse, who sent me back for an EKG. The technician who did the test said my heart was normal, but he knew that anxiety attacks are common among SAD patients, so he called down a psychologist who talked to me and diagnosed my condition. He suggested that I use a light box, and it’s helped me a lot."

The first step counselors take after diagnosing a patient with depression is to determine if the patient is suicidal and needs emergency inpatient treatment, says O’Brien. If not, they bring in a psychiatrist to decide if the patient needs medication to stabilize their conditions so they can focus on psychotherapy.

"Prolonged negative thinking associated with depression can cause an imbalance in the brain’s neurotransmitters," O’Brien explains. "Patients who’ve been struggling for a long time might need medications to bring their serotonin and GABA (an amino acid that inhibits excess anxiety) levels back up to normal."

The most common antidepressant drugs are selective serotonin re-uptake inhibitors, which work by preventing neurons in the brain from absorbing and recycling serotonin molecules, leaving them free to bond with neuro-receptors and elevate the patient’s mood. While SSRIs like Zoloft, Prozac, Paxil and others have been proven to effectively treat chronic major depression, they often induce side effects such as sexual dysfunction, nausea, abnormal sensitivity to light, and gastrointestinal bleeding when combined with anticoagulants or over-the-counter painkillers.

Children and teens who use SSRIs sometimes fall into suicidal depression, a 2004 Food and Drug Administration study revealed, although further research found no link between SSRIs and increased suicide risk in adults.

Some patients still use "first generation" antidepressants such as Marplan and Mardelzine. These drugs deactivate the enzyme that breaks down serotonin and other neurotransmitters, which increases the amount of those neurotransmitters in the brain without blocking their re-uptake. Though they work well for many patients, they interact with a number of foods and medicines, requiring some patients to avoid ingesting aged cheese, alcohol and other foods with a high yeast content, as well as over-the-counter painkillers and supplements like tryptophan and St. John’s wort.

Variations on SSRIs that combine serotonin uptake inhibition with inducing increased serotonin production, such as Oleptro, have recently won FDA approval, but no "third generation" antidepressant is poised to hit the market. 

"There are no ‘breakthrough’ drugs currently on the market," Teas asserts. "However, some newer drugs are in the clinical trial phase, such as ketamine derivatives that are unique and may offer some individuals faster or better outcomes in the future."

Patients who don’t respond well to medications or can’t take them have an alternative. Transcranial magnetic stimulation (TMS) applies mild magnetic pulses to the brain’s left prefrontal cortex to stimulate neurotransmitter production, explains therapist Steven Smith, director of Rosecrance mental health clinic, a regional facility with offices in Naperville and Oak Park.

"We’re winding up the (neurotransmitter) generator to the level that non-depressed people have," Smith says. "It’s an attempt to treat depression at its core — the brain itself — without affecting the patient’s body chemistry."

The patient receiving TMS sits in a reclining chair that looks like it came from a dental clinic. Electrodes are fastened to the patient’s forehead with a headband; then a machine transmits thousands of small magnetic pulses through the electrodes into the brain during the 20-minute treatment. It takes 25 to 30 treatments spread over four to six weeks to relieve depression symptoms, Smith says.

"We use the same technology as an MRI machine, except that the patient doesn’t have to lie in a tube," notes Smith. "Some of our patients call the machine ‘the woodpecker’ because it feels like something’s tapping on your head. It can be irritating at first, but a lot of our patients end up falling asleep during the procedure after the 25th treatment or so."

According to FDA protocols handed down when the agency cleared the TMS  device for use in 2010, patients can’t try it unless medication has already failed to help their depression or they can’t take antidepressants for medical reasons, acknowledges Smith. TMS therapy also works best when paired with behavioral therapy, he adds.

Patients who use antidepressants should also undergo cognitive behavior therapy, experts agree. "People shouldn’t depend on medication to stop depression," maintains O’Brien. "Medication is just a short-term measure to stabilize patients while they’re working on a long-term solution."

That solution usually involves cognitive behavioral therapy (CBT), according to Dr. Joann Wright, director of clinical training and anxiety services at Linden Oaks Hospital in Naperville. Developed to treat depression a decade ago, CBT is used to treat a number of mental disorders, including autism, anger management dysfunction and anxiety disorders.

"We all have a long-standing history of listening to our thoughts and taking them as the absolute truth," Wright comments. "That sets up patterns in our thought process that can damage our mental and emotional health."

Noting that most patients suffer from both depression and anxiety, Wright says those disorders often spring from real-life experiences that have damaged patients’ thought processes. "I’m loath to call depression and anxiety mental illnesses because they’re both rational responses to things that have happened to us," she asserts. "They might not be realistic — someone might be anxious around dogs because someone told them as a child that a dog would bite them — but they aren’t crazy."

Wright, a psychologist, uses several behavioral techniques to help patients resolve the experiences that prompted their chronic symptoms. One — acceptance and commitment therapy — teaches patients to accept fears and other negative thoughts that come into their minds, then commit to ignoring those thoughts in favor of accomplishing goals that align with the patient’s values. "Imagine that you can’t go to your family’s Thanksgiving dinner, even though you desperately want to, because there’s a person there that you have a panic attack just thinking about," says Wright. "Avoiding or denying that fear simply makes it stronger. Instead, you should face the fear, come up with coping strategies to deal with the situation, then commit to going to the dinner despite being afraid. Remind yourself that the enjoyment of being with loved ones is worth the pain of experiencing that fear."

Once patients work around their fears instead of avoiding fearful situations, they’re engaging in exposure therapy. "One of the beauties of exposure therapy is that the feared thing is rarely as bad as people think it will be," Wright notes. "One of my favorite patients had a crippling case of social anxiety, so bad that she could barely leave her house. Now she’s a Toastmasters-certified professional public speaker."

What’s in store for depression patients and their medical providers? "The major advance will be to ramp up proper identification and access to care," maintains Teas. "It is well known that persons with depression have negative outcomes on all aspects of their lives, including their medical stability from other disease states. As population health gains momentum, doctors will be more aware and active in referral and management of individuals with mood disorders, so access and care will expand. Research that guides specific psychotherapy interventions will improve training and help standardize treatments that are evidence-based."

For those suffering from depression — holiday-related or otherwise — that’s something to be positive about. 

Warning Signs of Depression

It’s normal to feel sad or sluggish at times, especially while weathering a personal crisis like divorce, unemployment or bereavement. But how can someone tell the difference between a temporary emotional downswing that time will heal and a clinical depression that requires professional treatment?

Here, from the Mayo Clinic, is a list of common warning signs that someone is suffering from depression:

-Chronic uncontrollable feelings of sadness, helplessness and despair;

-Loss of interest in favorite activities;

-Disruptions in sleep patterns, including insomnia and compulsive oversleeping;

-Chronic, unexplained lack of energy that interferes with performing routine daily activities;

-Frequent irritable outbursts, especially over small matters;

-Trouble focusing on routine tasks;

-Changes in appetite, including lack

of interest in eating and compulsive overeating;

-Fixating on past failures or losses, accompanied by feelings of guilt or worthlessness;

-Unusual restlessness or agitation;

-Recurrent thoughts of death, especially suicide.

People who regularly exhibit more than two of these symptoms for more than two weeks should seek treatment, either from a medical practitioner or informal counseling from a clergy member or trusted friend.  

Keys for Coping with Holiday Stress

Finding the perfect gifts, setting the perfect table and serving the perfect turkey dinner while wearing the perfect outfit in the perfectly decorated home, all while navigating through a minefield of social interactions with co-workers, friends and family . . .  it’s no wonder many people approach the holidays with misgivings.

For the 58 million Americans who suffer from depression and/or an anxiety disorder, meeting popular culture’s standards for the ideal Thanksgiving, Hanukkah, Christmas or other seasonal celebration creates far more stress than they can cope with. "They’re especially afraid of disappointing their families, their friends and themselves because they don’t want to be the one who spoils Christmas for everyone else," explains Kathy Gibson, a licensed professional counselor at Tri-City Family Services in Geneva, who advises companies on how to help their employees reduce holiday stress.

Here, from area mental health professionals, is a playbook to help everyone handle the holidays with less stress and more joy.

1. Set your own standards. 

"The biggest gift you can give yourself is to relax your expectations of what you want the holidays to be," Gibson advises. "If your family’s traditions involve too much preparation or are emotionally overwhelming for you, redefine them to fit within your limits while focusing on what’s really important."

For example, if you don’t feel up to hosting the big family Thanksgiving extravaganza as usual, you can still open your home to relatives, but arrange for everyone to bring a dish for a potluck meal instead of cooking a four-course dinner for 20.

 2. Plan ahead to stay in control of holiday interactions. 

"Decide in advance which situations you feel comfortable with and which ones you don’t feel up to at this time," suggests Anna Padron Sikora, associate vice president of Pillars mental health service in La Grange Park. Choose to attend only those functions that include supportive friends and politely pass on that big office party. "If you don’t plan psychologically for the holidays, you will feel bombarded by demands and out of control when they arrive," Sikora asserts.

 3. Change traditions that bring back unhappy memories or unpleasant associations. 

"Some persons have recall of losses during holiday occasions. The loss of loved ones is often re-experienced during holiday seasons," notes Dr. Greg Teas, a psychiatrist at Amita Health/Alexian Brothers Behavioral Health Hospital in Hoffman Estates. "Consider a novel way to celebrate that will not trigger memories of past events. Stay busy and try to share the time with others who can offer support or distract from negative thinking."

Don’t be afraid to jettison painful traditions for new ones that celebrate what’s good about life now. "Changing the way we celebrate holidays is part of life, as people leave the family group and new people enter it," says Gibson. "These changes don’t make the holidays any less meaningful."

4. Give family and friends advance notice of any changes to shared plans or traditions. 

"Let them know early on what limitations you’re putting on your participation to stay mentally healthy, and anticipate their reactions," Gibson counsels. "If you give them plenty of warning and explain why you need those limits, that often breaks down any resistance or disappointment they might feel."

 5. Build in safety nets for potentially over-stressful situations. 

"It’s OK to ask your host in advance for a small space where you can withdraw and be by yourself if you need to," states Dr. Joann Wright, director of clinical training and anxiety services at Linden Oaks Hospital in Naperville. Other strategies include enlisting sympathetic relatives to run interference or to slip out with you for a walk when the noise level gets unbearably high.

6. Don’t try to "treat" holiday stress overload with drugs, alcohol or unhealthy "comfort food". 

"Be aware that, if you are under excessive stress, alcohol and other drugs can be more seductive and may often worsen mood or unleash impulsive behavior," Teas cautions.