Hallmark Christmas movies aside, the holidays bring no joy to the whirl for some people, but rather a renewed or recurring period of deepened distress, despair and dysfunction. This may be especially true for certain patient demographics, such as teens, mothers and seniors.
And thus ‘tis the season for physicians to take note — to better watch out — for signs of psychological stress or worse in their patients, even those visiting them for entirely different reasons. We asked three psychiatric specialists at University of California San Diego School of Medicine for their thoughts and advice.
For many, perhaps most, teens, the holiday season is a happy time surrounded by family and friends — and maybe a cool gift or two. For some, however, particularly those living with mental illness, the season can trigger negative memories and/or add new stressors and challenges to already troubled lives, said
Kristin Cadenhead, MD, a board-certified psychiatrist and director of UC San Diego Health’s early psychosis treatment program, which focuses on recognizing and treating early psychoses before they become serious mental illnesses, like schizophrenia.
The holidays, said Cadenhead, can “affect teens’ moods and put them more at risk for coping in unhealthy ways, such as using substances, over- or under-eating, over- or under-sleeping, withdrawing from others or engaging in self-harm.”
It’s a time of particular challenges for young adults. They may be facing difficult final exams in school. If they’re in college and living away from home, they may find themselves feeling isolated, far from familiar surroundings and more likely to engage in poor coping strategies.
“Often, it’s up to parents and providers to notice mood changes, irritability or avoidance of social situations,” said Cadenhead. “Seasonal factors may play a role in how these problems may manifest. For example, not having as much sunlight can make teens feel fatigued. Because it’s colder outside, many teens won’t be as physically active, which can affect mental and physical health. Also, staying indoors often leads to isolation, which can increase loneliness and boredom, which can trigger suicidal ideations and increase risky, harmful behaviors.”
Cadenhead advises physicians to look for any unusual or harmful behaviors, such as drug or alcohol use or loss of interest. They should ask their patients how they are feeling: Sad? Lonely? Grumpy? How are their grades? What are they doing for fun?
If they detect signs of concern, they should immediately refer their patients to appropriate mental health providers.
For mothers, the holiday season can be simultaneously joyous and stressful.
“It can be overwhelming,” said
Alison Reminick, MD, assistant professor of psychiatry at UC San Diego School of Medicine and a practicing psychiatrist at UC San Diego Health, “particularly for the moms I take care of who struggle at baseline with anxiety.
“This time of year can be magical, but mothers tend to put it on themselves to create the magic. Too many moms have the responsibility of shopping — buying presents for the children, partner, extended family, teachers — setting up photos, sending Christmas cards, wrapping presents, decorating, meal planning, baking cookies and trying to live up to the unachievable Martha Stewart ideal of what the holidays should look like.
“The to-do list for making the holidays magical seems endless and can lead to worsening of anxiety, insomnia, irritability and poor self-care.”
Compounding the problem may be patients who had difficult childhoods or bad memories associated with the holidays. “It can add to the stress associated with creating a different experience for their children,” said Reminick, who specializes in treating women with mental health care needs.
The holidays can also evoke other painful associations: infertility, reproductive loss or the loss of a child or family member, divorce or the challenges of coping with a child with special needs. “The holidays can be a reminder of the vision they held of what life would look like for these special moments (and how it is not their life),” said Reminick.
“It’s normal to feel the need to grieve that loss at the holidays, though this kind of disenfranchised grief can be hard to acknowledge and process in our culture.”
Beginning in October, Reminick looks for indicators of a change in mood or behavior in her patients, such as sleeping too little or too much, gaining or losing weight, withdrawing socially or expressing unusual levels of irritability or worry. As a doctor, Reminick listens and validates her patients’ feelings, urging them to make time to take care of themselves (such as going for walks or quiet time breaks) and perhaps outsourcing household tasks, such as housecleaning or meals. “I ask, ‘Who can help you with that?’ It’s OK to ask for help from supportive people.”
She also informs her patients in advance when she will be away so that they can plan accordingly, but leaves four or five slots open on her weekly schedule for patients who might need to see her urgently.
For many older adults the winter holidays are a rewarding and enjoyable time but, for some, the holidays can be confounding and contradictory. They may conjure sad memories of family and friends now gone or re-introduce them to old family disputes or dysfunction. Or the holidays can mean too much of a good thing or simply too much, too many people, too many activities or too much food and drink.
“For doctors and for patients and their family members, the holidays can be revelatory, perhaps the first time when younger people who haven’t seen their older parents or others in some time realize that everything is not quite right, that there may be a question of dementia,” said
Dan Sewell, MD, professor of psychiatry at UC San Diego School of Medicine and co-director of geriatric psychiatry at UC San Diego Health.
“Such things must be handled well, with emotional intelligence. Are older persons included in the festivities? Are they being marginalized or talked down to? Are they comfortable and enjoying themselves? People have to be sensitive to the fact that older adults, especially those living with dementia, might be more easily tired or overstimulated. They might need food, water, help to the bath room or time away to rest and possibly take a nap.”
For primary care physicians seeing older patients during the holidays, Sewell suggests looking for signs of concern. People are more vulnerable to mood disorders during holidays. “It’s important to know that older adults may be pretty depressed and not tell a doctor. They may not display tearfulness or melancholy. In later life, people can meet the diagnostic criteria and never shed a tear. Instead, they’ll become irritable.”
Sewell advises asking a few benign questions: What are their holiday plans? Do they have family traditions?
“Depending on what a doctor hears, he or she might follow up with more questions about how they feel about things. Are they OK with what’s going on? The call for help may be subtle, such as a patient saying his family is doing very well and doesn’t really need him anymore. It may sound like bragging when really they’re saying they’re lonely and feeling without purpose. If possible, a physician should take a moment to help problem solve with the patient. If that’s not possible, the physician should know of resources that can help.”
Note: A new resource for clinicians who care for patients living with dementia is the San Diego County Alzheimer’s Project, which discusses guidelines, diagnostic tools, treatments and continuing medical education.
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