Seasons, celebrations and 'the blues'

The holidays are upon us, and too many depressed people go untreated.

It isn't a coincidence that in Israel, the major Jewish holidays (such as Rosh Hashana, Succot and Pessah) the changing of seasons and an increase in depression occur at the same time. These phenomena are intertwined, says Prof. Joseph Zohar, director of the psychiatry department at Sheba Medical Center at Tel Hashomer. For many people, inviting relatives and friends over for meals in the succa and preparing for Pessah or being someone's guest is a joyous occasion, as it gives the opportunity to show off hosting and social skills and reunites them with loved ones they have not seen for some time. But for others, holidays are a time of pressure, anxiety and inter-family conflict. Singles may feel so lonely that they prefer to leave the country during the holidays so as not to feel out of place. And people with social phobias who are "allergic" to gatherings will especially suffer. Despite the very family-orientedness of the religion and society here, the phenomenon is not a "Jewish thing." Seasonal affective disorder (appropriately known by its acronym SAD) caused by fewer hours of daylight is a well-documented phenomenon around the world, especially in countries more distant from the equator. SAD, first noted before 1845 but not officially named until the early 1980s, is a mood disorder associated with depression and related to seasonal variations of light. Melatonin, a sleep-related hormone secreted by the pineal gland in the brain, has been linked by some researchers to SAD; because more of it is produced in the dark, when the days are shorter, excessive amounts of the hormone may cause symptoms of depression. As sunlight affects the seasonal activities of animals (such as their reproductive cycles and hibernation), SAD may be an effect of this seasonal light variation in humans. As seasons change, there is a shift in our "biological internal clocks" or circadian rhythm, according to some experts due partially to these changes in sunlight patterns. This can cause our biological clocks to be out of step with our daily schedules. Those who habitually absent themselves from family or social events may be trying to cover up for social phobias, which during the holiday season can spark such intense feelings of anxiety and dread that they avoid gatherings altogether. Many people are anxious in social situations, such as when meeting new people at a holiday party, but the fear is not severe and typically passes, says Dr. Una McCann, chief of the anxiety disorders unit at the US National Institute of Mental Health. "For people with social phobia, however, the fear of embarrassment in social situations is excessive, extremely intrusive and can have debilitating effects on personal and professional relationships." The lifetime risk for depression in all populations ranges between 15 percent and 18% of the population, says Zohar, but it becomes more common when the seasons change. Since in Israel the climate produces only two main seasons winter and summer, with only fleeting spring and autumn mood changes tend to concentrate along the two seasonal changes in the year. Zohar says that changes of the seasons alone even without the pressures of holidays are enough to increase the incidence of anxiety and depression. "We aren't sure why, "but the holidays are an environmental factor that interact with the biological one." The holidays can be a trigger, but not the cause. If people have a predisposition to depression, the holiday stress could bring it about. Zohar does not believe that depression at changes in the seasons is necessarily connected with weather and the different proportion of light and darkness. "There is a rhythm in our lives, and along the annual cycle there is a varied tendency to develop disease." Phototherapy exposure to bright artificial light is commonly used in countries that have long periods of darkness during the day. Although there have been no research findings to definitely link this therapy with an antidepressant effect, many people respond to this treatment. The device most often used today is white fluorescent lights installed on a metal reflector and a plastic shield. For mild symptoms, spending time outdoors during the day or arranging homes and workplaces to receive more sunlight may be helpful. One study found that an hour's walk in winter sunlight was as effective as more than two hours under bright artificial light. Zohar notes that because Israel is located quite close to the equator and enjoys many cloudless days even in winter, the need for light therapy is significantly less than in countries farther away from the equator, but there still are people here who need it. Depression is twice as common in women than in men, but the reasons are not clear, the Sheba psychiatrist notes. Among the common warning signs are lack of or sometimes too much appetite, difficulty enjoying things one is used to enjoy, mood differences between morning and night, sleep problems and the tendency to look at the present and future through a dark prism. "One's accomplishments seem minimized and difficulties seem impossible to deal with as if you focus on the empty half of the glass rather than the half-full part. There may be less interest in sex, and often people lose weight because of appetite loss. Children too can suffer seasonal depression, but the problem is expressed differently among them; they may show a decline in self-control and good behavior and their studies." What should a person do if he sinks into depression? Zohar stresses that people should understand that depression does not mean weakness. "You shouldn't feel as if you've failed as a human being if you feel depressed. It is a brain disease caused by an imbalance in neurotransmitters that is made worse by environmental pressures. If your predisposition to depression is naturally lower, when you're forced to cope with difficult conditions you're less likely to get depressed. If you are strengthened by social support, your risk is also lower." Some people who have heard of St. John's wort a natural herb (Hypericum perforatum) said to relieve mild depression take pills made from it and sold in natural health stores and pharmacies. Four years ago, researchers at Duke University Medical Center in North Carolina wrote in Public Health Nutrition that although this increasingly popular herbal supplement appears promising in treating depression, many questions remain about its safety and effectiveness. After performing a rigorous, systematic meta-analysis of all previous studies of St. John's wort as a treatment for major depressive disorder, lead researcher Dr. Murali Doraiswamy concluded that the research shows "a need for caution, especially for patients on certain medications including tetracycline, cyclosporin, protease inhibitors, digoxin, warfarin, some oral birth-control medications and those used for asthma." Their research set off alarm bells, as in the US alone, over $250 million worth of St. John's wort products are sold each year. Doraiswamy says there is some evidence that St. John's wort may induce certain enzymes in the liver to process those types of medications faster than usual, resulting in lower effective doses of those drugs in the body. "The herbal supplement St. John's wort appears to be a promising antidepressant," wrote Doraiswamy. "But it has not yet been proven to be as effective as newer prescription antidepressants. Therefore, if people are suffering symptoms of depression, they should not self-medicate. Instead, they should consult a health-care provider." In addition, St. John's wort has not been tested as an effective medication for preventing the recurrence of depression. Zohar agrees that symptoms of depression that are serious or that persist for more than a week or two should not be treated with this herb. Instead, go to the doctor. The good news is that effective treatment for social phobia is available and can be tremendously helpful to people living with this disorder. Effective treatments include medications, a specific form of psychotherapy called cognitive-behavioral therapy or a combination of the two. Medications include antidepressants called selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes. People with a specific form of social phobia can be helped with beta-blockers. Cognitive-behavioral therapy teaches patients to react differently to the situations and bodily sensations that trigger anxiety symptoms. For example, "exposure therapy" helps patients become more comfortable with situations that frighten them by gradually increasing exposure to the situation. Since it is so common, the first medical practitioner to see is one's family physician or general practitioner who knows you and your other ailments. Referral to a psychiatrist is necessary only if it's a difficult case that does not easily respond to medications or talk therapy. "Many people are afraid to take medications because they believe they are addictive. But they absolutely aren't," Zohar insists. "They don't change personality. Unlike tranquilizers, they deal with biochemical imbalance in the brain. And they take a few weeks to take effect, so don't expect the depression to dissipate after taking them for only a day or two." Some of the prescription drugs on the market work on one neurotransmitter, but others, such as Cymbalta (Eli Lilly Pharmaceuticals) and Ixel (Pierre Fabre) work simultaneously on two, such as serotonin and norepinephrine (noradrenaline). "Some of the drugs are in the basket of health services supplied by health funds as part of the basket. There may be some side effects, such as weight gain or a reduction in sexual drive, but they are all reversible," he says. Depression is unfortunately undiagnosed and untreated in many cases. "The health funds must do more to increase awareness among the public and the doctors. We estimate that only about an eighth of depression cases are identified and properly treated. This is a shame; one shouldn't be ashamed of it. There are very effective treatments for depression," Zohar concludes, and they usually should be taken for another half a year or even a year after the depression passes to reduce the risk of return.