Christmas cards: are senders full of joy and good cheer?

Abstract People with depression often struggle with Christmas. The festive period is often associated with parties, social engagement, putting up Christmas trees among other behaviours. Here, in a large UK population level dataset, we examine whether higher depressive symptomatology was associated with frequency of sending Christmas cards, and if this varied by religious affiliation. Retrospective observational study. Participants were 2,416 individuals within the UK who completed data from 2013 to 2015 within Wave 5 of the longitudinal survey ‘Understanding Society’. Data on depressive symptoms 12-General Health Questionnaire, frequency of sending Christmas cards, and religious affiliation were extracted. A higher percentage (54.5%) of those without depressive symptoms reported ‘Always’ sending Christmas cards, compared to 46.0% of those with depressive symptoms χ2 (2) = 8.71, p < .001. After adjusting for religious affiliation, this remained significant only for Christians after holding, gender, relationship status and ethnicity constant. Christians with depression (20%) were more likely to ‘Never’ send Christmas cards, while those not depressed were 53% more likely to ‘Always’ send them, p < .01. In those identifying as Christians not sending a Christmas card was significantly associated with depressive symptoms. This might help provide a way to identify loved ones, friends or colleagues who may need help and support at Christmas.


Introduction
Although Christmas is a much-celebrated festive season, it is also one that elicits mixed feelings.A recent poll from 2019 has found that while Christmas isa happy time for most, a quarter of people surveyed said it makes their mental health worse (Nolse, 2019Carley & Hamilton, 2004;Cavanagh et al., 2016).In fact, this increased risk of depressive symptoms at Christmas stems from a phenomenon psychiatrists refer to as the 'Holiday Blues' (Cattell, 1955;Hillard & Buckman, 1982;Sattin, 1975).These authors have described this phenomenon as feelings of helplessness, increased sadness and irritability experienced during the holiday season, including Christmas, while others have described it as a stress reaction to Christmas (Baier, 1987).From a psychological perspective, these depressive like symptoms are more likely to occur in response to social threat, whereby some individuals may feel stressed in anticipation of financial pressures, increased social isolation, loneliness if they have lower social networks (Peretti, 1980).Other research has confirmed that while general mood decreases over the festive period, there is an under-utilization of services for inpatient psychiatric care (Sansone & Sansone, 2011).In this paper, we examine a common festive behaviour, sending Christmas cards, and what this one Christmas act can tell us about a person's mood.
In the 1840s, Prince Albert introduced many German Christmas traditions to the British public, including the decorated Christmas tree.Following this, in 1843, Henry Cole, founder of the Victoria and Albert museum sent the first Christmas Card (see above) in 1843 (just three years after the publication of the first issue of the BMJ; Victoria and Albert Museum, 2021) and now billions of them have been sent to mark the festive season, with an estimated 1 billion sent each year in the UK alone (Association, 2021).Although traditionally associated with a Christian holiday, Christmas is both a cultural and a religious event, celebrated in Christian and non-Christian countries alike (McKechnie & Tynan, 2006).While in recent years, sending letter post has been in decline, in Christmas 2020, the exchange of Christmas Cards increased (YouGov, 2020).But what can the sending of Christmas cards tell us about the sender?In fact, research has found that prosocial gestures of expressing gratitude in letters and cards has been found to boost positive emotions in both the receiver and sender (Kumar & Epley, 2018).Can Christmas cards be considered more than just the exchange of pleasantries and good wishes over the festive season?Could Christmas cards, in themselves, offer proxy measures of the senders' mood?
Anhedonia is a feature of depression and is defined as the loss of experiencing pleasure in a variety of behaviours (APA, 2013).Moreover, given that sending Christmas cards, like other greeting cards, are often viewed as a social pleasantry and as way of a conveying a person's feelings and mood (Henry, 1947;Kumar & Epley, 2018), it is therefore plausible (Steger & Kashdan, 2009) and studies have also found that greeting cards provide an ideal opportunity for researchers to capture the role of these social processes (Cacioppo & Andersen, 1981).Utilizing a large UK population-level dataset, the Understanding Society-The UK Household Longitudinal Study (Essex, 2020), we explore what Christmas cards might tell us about the mental health of the sender.Specifically, based on studies showing that sending and writing greeting cards to be associated with positive mood (Kumar & Epley, 2018), we expect those who do not send Christmas cards to report higher depressive symptomatology.

Study design and participants
The Understanding Society dataset in the UK (Essex, 2020) is a longitudinal survey study of approximately 40,000 households in the United Kingdom and conducted every 2 years.We used data from Wave 5 (2013)(2014)(2015).At this Wave, participants were asked 'Do you or your family do any of the following' 'Send Christmas Cards'? with response categories from Always = 1, Sometimes = 2, Never = 3 and don't know what this is = 4).A total of n = 50 indicated that they 'don't know what this is' and these were therefore removed from the sample.Given that Christmas is a Christian holiday we also examined religious affiliation as a moderator in our analyses.Participants were asked, from a list, their religious affiliation (e.g., Church of England/Anglican, Church of Scotland, Roman Catholic, Presbyterian, Baptist, Methodist, Hindu, Muslim, Jewish, Sikh, Buddhist, other and no religion).This was collapsed into Christian (all Christian faiths), and others (all non-Christians and non-religious).While 5,153 people responded to Christmas card question in Wave 5, after applying the religious affiliation data we were left with 2,416 participants.All participants from the Understanding Society Study gave informed consent and ethics were obtained by the University of Essex, UK from National Research Ethics Service (NRES) Oxfordshire REC A (08/H0604/124).
The results sections has all other relevant sociodemographic breakdown (e.g.age, gender, marital status, ethnicity, education, income (monthly)).We dichotomized relationship status (married/partnered vs unpartnered), ethnicity (White vs Black and minority ethnic) and education (University Degree vs No Degree).

Depression symptoms
At Wave 5, the 12-item General Health Questionnaire (GHQ) captured depressive symptoms.(Goldberg et al., 1997).The scale has been adopted as a screening tool in an international World Health Organization (WHO) study of psychological disorders in primary health care (Goldberg et al., 1997).Items (e.g.unhappy or depressed) are scored as 1 = not at all; 2 = no more than usual; 3 = rather more than usual; 4 = much more than usual.Responses of 1 or 2 are scored as 0, and responses of 3 or 4 are scored as 1.A total score ≥6 is specific and sensitive at identifying those with or without a depressive disorder (Lundin et al., 2016).This served as our grouping variable.

Statistical analysis
Data was screened and revealed no outliers.Initial analyses focused on tests of differences to examine group difference across depressive symptom status on sociodemographic variables and frequency of sending Christmas cards.This latter analysis on Christmas cards was also repeated to test for variation by religious affiliation.Multinomial logistic regressions was then employed to confirm whether any of the associations above between depression symptoms status (depressed vs non-depressed) and sending Christmas cards (e.g.Always, Sometimes or Never) was independent of confounding/covariates (e.g.sociodemographics).Odds ratio (OR) is our effect size.

Results
The details of the respondents are contained in Table 1.There were no age, income, education or religious affiliation differences seen across the depressive symptoms categories (seeTable 1).However, those with depressive symptoms were more likely to be female, single/unmarried, and be Black and minority ethnic.Further, a higher percentage of those who did not display depressive symptoms endorsed the 'always' sent Christmas cards category more than those who did have depressive symptoms.We tested whether depression effects on sending cards varied by religious affiliation and found they were only evident for Christians χ 2 (2) 12.51, p = .002,and not those of other affiliations, χ 2 (2) 1.35, p = .54.Compared to Christians without depressive symptoms, Christians with depressive symptoms were less likely to endorse 'always' sending Christmas cards, as well as endorsing 'never' sending Christmas cards (see Figure 1).

Depressive status and sending Christmas cards in Christians
To investigate if our depressive symptom category was still associated with sending Christmas cards after controlling for gender, relationship status and ethnicity a multi-nominal logistic regression was performed (See, Table 2).Within this analysis, the 'Always' sending Christmas card cohort served as our reference group.After holding gender, relationship status and ethnicity constant, there was no association between depressive symptoms and the 'Always' and 'Sometimes' groups.However, when the reference was compared to 'Never' a different picture emerged.Here a significant association between depressive status and the 'Always' and 'Never' sending cards groups.After holding, gender, relationship status and ethnicity constant, those with depression were more likely to 'Never' send Christmas cards, while those not depressed were 53% more likely to 'Always' send them.

Discussion
The present study found, in a large UK-based sample, that depressive symptoms was associated with the sending or not of Christmas cards.To our knowledge, this is the first study to demonstrate such an association.Those who were categorized as depressed based on cut-off scores were more likely to 'Never' send cards, while those who were not depressed were more likely to "Always" send them.Moreover, these effects were only evident for Christians and not the other religious category, namely non-Christians and not belonging to any religion.Further, this pattern was still evident after accounting for well-established risk factors for depression such as gender, relationship status and ethnicity.Therefore, the measurement of how depressed a person is a potential indicator of how often a person engages in the sending of Christmas cards by the sender, for Christians in any case.
One reason why depressed people are less likely to send Christmas cards is perhaps linked to social-anhedonia, a deficit in social bonding and affiliation which is often seen in those with depression (Kupferberg et al., 2016).Further, the sending of Christmas cards is often an exchange and as such, is associated with the reciprocity norm, where one engages in altruistic behaviour with the assumption that this altruism will be returned (Cialdini, 2001).Depression is associated with decreased motivation for reward (Treadway et al., 2012) and as such depressed people may not engage in typical patterns of reciprocity.It has also been argued that the fundamental purpose of sending Christmas cards is to renew and strengthen social bonds (Gooch & Kelly, 2016), as such, in order to send Christmas cards one must first have a social  network to Christmas cards to.While we did not assess social networks in this study, research does confirm that those who are depressed report less social support compared to those not depressed (Gariépy et al., 2016;Kupferberg et al., 2016;Lee et al., 2019).Thus, this may be an area for future research.
Alternatively, given the cross-sectional nature of the data could it also be that sending a card a proxy for depression?Perhaps so.The sending of cards requires a level of motivation to buy or create the cards, write them, engage in the pleasantries of wishing someone a merry Christmas, and for those who may be experiencing low mood, this can be a challenge.Certainly, for those that are depressed, low motivation is a key element (Treadway et al., 2012), which would directly affect the engaging of the organizational and physical act of sending Christmas cards.Despite this, our findings were only relevant to Christians and while Christmas is celebrated by many, it is primarily a Christian holiday thus Christians are more invested and more likely to engage in those traditions.It is worth nothing that a higher percentage of Christians were more likely to 'Always' send cards compared to the other group (69.6% vs 37.2%).
While there are several strengths of the study including a large sample size, population-based study, use of reliable index of depressive symptoms there are limitations.First, the cross-sectional nature of the data prevents us from inferring causality.Second, the item assessing sending Christmas cards asked 'if you are your family' sends them.Thus, caution is warranted when interpreting the findings as even though the individual responded we cannot say for certain if this it was an individual or household behaviour.Second, the scale used is a self-report measure and may only capture symptomatology rather than confirmed diagnosis.Third, there are a number of other potential variables we were unable to control for, such as the general health of the individual, their mobility, and even their proximity to a post office; all particularly important factors that may come into play when actually completing the job of sending Christmas cards.But what's is the clinical utility of such information and how could it be used.Given that not sending a Christmas card might be indicative of lower mood then checking in on a loved one, friend or colleague who doesn't send us that card where ordinarily they would've is a wise and kind thing to do.Mentioning that you missed receiving their card and asking if there is anything that is troubling and offering to listen may be the best Christmas gift you can give someone.Further, social prescribing, also known as community referral, is growing internationally recognition as a health and social care initiative with benefits for individuals and social groups to improve their health and wellbeing (Cunningham et al., 2022).This involves a health or social care professional signposting individuals to appropriate community-based opportunities (physical, mental and/or social), for example, a local art therapy club, jogging group to increase physical activity levels, or a hobby club to reduce feelings of loneliness.Thus, for those who may be experiencing depression, an social prescribing initiative around sending Christmas cards is one that could be easily done as part of an art therapy programme, programmes that are feasible to run in primary care settings (Barley et al., 2012).In conclusion, sending Christmas cards can signify if someone is going to have a 'merry' or a 'blue' Christmas so let's keep an eye out for those on who don't send us that card.You are free to: Share -copy and redistribute the material in any medium or format.Adapt -remix, transform, and build upon the material for any purpose, even commercially.The licensor cannot revoke these freedoms as long as you follow the license terms.
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Figure
Figure 1.Depression, frequency of sending Christmas cards of Christian groups.

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