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Primary Care Physicians are the First Line of Defense for Patients with the Holiday Blues

  • December 12, 2012
  • Number of views: 3621
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As much as this 'tis the season to be jolly, the stress and expectations inherent during the holidays can lead to depression.

"It's very common to have the blues and intense feelings and emotions around the holidays," said Dr. Randi Mozenter, a clinical psychologist with Barnes-Jewish Hospital in St. Louis. "Clearly a lot of people have unmet expectations and frustrations and intense loneliness around the holidays."

Often, the primary care physician (PCP) is the first medical professional to hear about these problems.

"Because it's cold and there's more illness going on, the PCPs may be seeing and hearing about more problems from the patients around the holidays than at other times," said Dr. Mozenter, who also has a private practice. "It's not the blues bringing them to the PCP. It's other things, and then they may very well mention emotional factors as well."

Patients won't necessarily directly mention a case of the blues, so doctors need to watch for symptoms.

"You're going to look for changes in sleep patterns, appetite, energy, concentration, a kind of general well-being," Dr. Mozenter said. "A lot of physical symptoms, most internists will tell you, raise a lot of red flags in terms of, ''Is there a depression going on?'' Such as headaches, stomachaches, back pain, muscle aches, any kind of chronic feeling of malaise that's lasted more than a couple of weeks and doesn't seem to be associated with any significant known physical illness.

"The other big one is changes in concentration, attention span, forgetting, libido," she said. "Oftentimes that will bring someone in because they're thinking, ''Well, that's physical. Maybe I'm losing my mind. Maybe it's early Alzheimer's. I don't know what's going on. I'm frightened.'' But oftentimes those low level, chronic problems are a sign of an early depression. The other thing is any kind of anxiety symptoms, especially if there's a recent onset and it's a change from the person's baseline. Oftentimes those may be more a sign of depression than an anxiety disorder."

Worrying, nervousness, tension and unease are all potential warning signs.

"If the person is reporting pretty significant change in symptoms, unremitting for about a week or so, that's probably enough time to pay attention," Dr. Mozenter said.

A thorough examination should be able to determine whether a person has actual physical ailments or depression-related problems.

"If all the findings are negative, that's a good sign," she said. "The other thing to look for is the cluster of symptoms. If someone is coming in and they're reporting sleep problems and appetite problems and energy problems and decreased libido and not being very motivated and not feeling very well, and they've got all those things together, a depression is one of the things that should be considered and evaluated, as well as other medical conditions."

PCPs often consult Dr. Mozenter before making a final call about a patient's depression.

"They'll call me and talk about some general things and then go ahead and get the person started on an SSRI (selective serotonin-reuptake inhibitor)," she said. "The majority of SSRIs in this country are prescribed by PCPs. As long as ... the depression is at a mild to moderate level and there isn't suicidal thinking or any psychotic symptoms, an awful lot of PCPs are comfortable starting a patient on an SSRI.

"The problem is, because so many PCPs are not that comfortable, a lot of times what will happen is they will start a patient on an SSRI and they may not increase the dose high enough," she said. "So a psychiatrist, for example, might be much more comfortable pushing that dose up, whereas a PCP may not. And then the patient doesn't respond and the drug is seen as a failure, when it wasn't the drug itself, it was the dosage. So it's important to educate the PCPs as much as possible about the range of doses that patients might need."

Combining cognitive behavioral therapy with an SSRI is "the treatment of choice," Dr. Mozenter said. "A lot of PCPs are very comfortable referring to clinical social workers, therapists, psychologists. Some are not, and what they say to me, although less in recent times, is they're afraid their patients are going to be offended. The patient says, ''You think I'm crazy? You don't think my symptoms are real?'' It's important to be comfortable discussing it with your patients in terms of ''I know your symptoms are real. I know you're suffering. This is brain chemistry at work. But that doesn't necessarily mean you're going to need medication, because stress and strain does have a physical impact on a person.''

"Especially around the holidays, a little bit of counseling can go a long way," she said. "Because oftentimes there are issues that people can put their fingers on, like, ''Of course I'm feeling kind of down. I lost my spouse this year.'' Or, ''Everyone else has a happy family, and my family hates each other.'' Or, ''I'm lonely. It's just the state of things, so counseling or medicine wouldn't help.'' And that's not true. Because what they both do in their own way is to help the person come up with new options, to think more clearly, to problem solve and cope."

Cognitive behavioral therapy is an effective method, Dr. Mozenter said.

"That's where the research really shows great results," she said. "That therapy is really based on dealing with the way we think, and how our thoughts and interpretations of events lead to our feelings. And how that has a direct impact on our physical well-being."

Discussing a patient's feelings about the holidays can start the healing process, Dr. Mozenter said.

That way, she said, it's possible to "see what the options are and work on more effective problem-solving methods to generate better solutions or approaches to deal with some of the frustration of the holidays. A lot of people have very, very unrealistic expectations of the holidays, and that really compounds how they feel."

People often feel there is no solution, but PCPs should encourage dialogue.

"Sometimes looking at it differently or sharing thoughts and feelings with somebody else and coming up with a different approach may really help," she said. "Sometimes just talking the problems out and sharing them is a huge release and really does make a big difference."

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