The December holidays are a sad, melancholy, or even depressing time for many people. My heart goes out to all who feel that way. I’ve witnessed and felt that pain, too.
Every year like clockwork, my father would go into a funk in early December, from which he would not emerge until Dec. 26. Fortunately, my mother more than made up for his depression—his word—with her overflowing Christmas spirit. She had enough warmth and cheer for everyone.
Dad had a strict religious upbringing in rural Illinois. In his family, Christmas meant a box of candy and church worship, not gifts around an ornamented tree. After he went to college, and from there to medical school, he radically changed his religious beliefs and practices, but he never got over his childhood wounds about Christmas. The way my mother celebrated the holiday was alien for him, and he really didn’t know how to behave. Receiving gifts was especially hard for him. He forced himself to participate in our merriment and eventually had fun creating traditions of his own, but he never got over his December depression.
Now that Dad’s gone, I view Christmas with some sadness. The first Christmas after his death was especially painful for me. I could not simply pick up where my family had left off the previous year, when Dad was still a part of our celebration. That first Christmas, I visited his grave in an inconsolable state late on Dec. 24th and the next day announced to my family that we had to change our traditions. The next year, I insisted that we invite a good family friend, who otherwise would be alone on Christmas, to join us. She’s returning this year, much to my delight.
This Christmas, we also have a new family member: a 12-year-old rescue Shih Tzu named Rocko, whom I adopted in April. I think he’s getting a sweater.
PSYCHOSOCIAL RISK FACTORS
I write extensively about depression in “Our Parents in Crisis,” in a chapter I titled “Depression and Delirium: A Complicated Picture.” That there continues to be a stigma attached to depression and other mental illnesses angers and frustrates me; such ignorance interferes with therapeutic intervention. People who need help don’t get it.
In my book, I write: “Depression in older people is complicated. . . . [Y]our Mom’s or Pop’s depression can be an illness itself; a sign of another illness; or a psychological reaction to illness.” I then define depression, according to the latest “Diagnostic and Statistics Manual of Mental Disorders” (“DSM”), which requires the presence of a certain number of telltale symptoms, such as insomnia, weight loss, or fatigue, nearly every day during a two-week period. At least one of those symptoms must be either a depressed mood or anhedonia, which is defined as a markedly diminished interest or pleasure in all, or almost all, activities.
Some of the psychosocial risk factors—aka depression stressors—that are especially relevant for older people include:
*Social isolation [a major problem at all ages]
*An empty nest
*A move into an apartment, retirement facility, or nursing home
*The death of a spouse or friends
*Chronic and/or severe pain
*A loss of independence and control
QUESTIONS TO ASK
No one depressed person is like another. In “Our Parents in Crisis,” I focus on elderly parents and advise anyone who suspects that his or her mother or father is depressed to ask the following questions, which are based on “DSM” criteria. Is your parent:
§ “Sleeping too much or too little? (Having trouble getting to sleep? Staying in bed all day?)
§ “Acting irritable and/or intolerant? (More so than usual?)
§ “Moving restlessly or more slowly than usual? (Fidgeting?)
§ “Lacking in energy and motivation? (Not leaving home?)
§ “Complaining more about physical aches and pains?
§ “Being more confused or forgetful?
§ “Eating less? (Is the refrigerator empty? Does it contain spoiled food?)
§ “Not bathing or shaving as often? (Is he/she wearing the same outfit every day?)
§ “Not taking care of the home? (Is trash piling up?)
§ “Stopping medications or taking them incorrectly?
§ “Withdrawing from others? (Failing to answer the phone or to return phone messages?)
§ “Crying too often or too much? (For no articulated reason?)
§ “Expressing recurrent thoughts of death or suicide?
“. . . I would advise that if you answered yes to any of these questions, you should make an appointment for your parent with his or her primary-care physician. To ensure that the doctor receives an objective account of the symptoms, accompany your Mom or Pop and relate what you have observed. . . .
“The doctor should conduct a history and a physical exam. If clinically indicated, he or she also should arrange for blood and urine tests to determine if a physical illness is causing your parent’s depression. But don’t let the doctor engage in test-overkill. Make him or her LISTEN and be on your guard.
“Primary-care doctors reportedly fail to recognize major depressive episodes in up to 50 percent of their patients of all ages. (If the patient doesn’t mention depression, the time-pressed PCP is not likely to bring it up.) They also mistake depression in older people for dementia, as well as fail to distinguish when an Alzheimer’s patient is depressed. (endnote)
“Yes, it may be difficult to differentiate in an older person those somatic (bodily) symptoms that are related to depression and those that are related to coexisting physical illness. Yes, elders often have chronic medical illnesses or pain syndromes and unexplained physical symptoms. But medical professionals are supposed to be able to make the necessary cause-and-effect distinctions.
“Primary-care physicians can do much more than they currently do to uncover cases of depression, starting with asking more on-point questions and listening to their patients’ responses. Questions such as ‘How are things at home?’ or even ‘Have you been feeling sad/depressed/blue lately?’ can elicit valuable information. Communication + empathy = results. (endnote)
“Assuming your Mom’s doctor diagnoses depression, she may be treated in primary care or referred to a psychiatrist. The duration and severity of her depression should determine the choice. Cognitive impairment, if a factor, also should be weighed.
“PCPs commonly prescribe antidepressants, but they do not engage in structured psychotherapy (talking), which has been shown in studies to benefit more elders than once thought. . . .
“In choosing an antidepressant for your Mom, the PCP should consider her prescription drug history, both in terms of efficacy and adverse effects. The potential for an adverse interaction between the antidepressant and her preexisting medications also is important to evaluate. People 65 and older have a lower tolerance for unwanted effects of antidepressants and are more likely to have cardiovascular disease and other medical illnesses that might complicate their pharmacologic treatment. Brain levels of chemical messengers, such as serotonin, norepinephrine, and dopamine, usually decrease with age. For this reason, older people should take lower doses of antidepressants that regulate one or more of these transmitters. . .
“Count yourself lucky if you have a Mom or Pop who articulates her/his depressed mood and/or anhedonia and asks for help. I think it is more likely that your aged parent will not talk about depression, instead stoically enduring it, rationalizing it as normal, or being so lethargic as to not want to discuss it. Cognitive impairment may complicate her or his awareness. Don’t let a lack of perception complicate yours.”
Merry Christmas, Happy Chanukah, Warm Wishes on Whatever-Holiday-You-Celebrate and the Winter Solstice, and Season’s Greetings. I’ll return in the new year with an optimistic look forward.