Welcome to the Psychofarm podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis, or treatment. Listening does not create a doctor-patient relationship with me or Dr. Fu. If you're a patient, certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a clinical reference or substitute for your own training, judgment, thinking, and up-to-date sources.
Opinions are our own and don't necessarily reflect any employer or affiliated organization and may even be detached from reality.
Good morning, Dr. Malesberg.
Good morning.
Are you feeling depressed today?
I'm not feeling too bad.
Me neither, but I bet there's a lot of people out there who do.
Absolutely. And I think that's the people we want to be talking to today.
That's right. I think we should introduce briefly who we are and why we're making this type of episode.
Absolutely. I'm Dr. Malzberg. I am a clinical psychiatrist and I make podcasts and media to make psychiatry make a little bit more sense to people.
I'm Dr. Fu. I'm a general and forensic psychiatrist. I teach at several places. And most of my work is still clinical, though.
Yeah. So I guess to give us a little grounding, our goal for this podcast is I want to do a series of what I wish patients knew about their diagnosis. And then I want to go through the major diagnoses. Because what I find is... So, you know, I treat a lot of depression. And I actually find I have the same kind of things come up again and again.
And I have a lot of overlap in terms of what I'm teaching patients. And I wanted to create a resource that would help providers hear the things that I think are important to communicate to patients. And also a resource that providers can send to patients so that the patients can get a good hour of psycho-ed about their diagnosis and how to think about it.
Supposed to be dual use, but I will say, I think even if you're a seasoned clinician listening, I hope you don't skip this because you may find that it strengthens your existing abilities and knowledge, or you may even Learn a new way to explain something. Because the educational component, I think, is underrated in the practice of psychiatry. So much of what actually makes a patient better is the therapeutic alliance.
And that's specifically, most of it is a understanding of what the problem is, what the goals are, and how to get to that goal and how to treat that problem. And if you don't give the right education about what you're doing and why and whose job is to do what, people aren't going to get better. So I hope you do listen.
Yeah, and I actually find I sometimes learn the most from things that are like oversimplified or dumped down a little bit. And I'm not saying that we're doing that, but there are guides for primary care doctors on different psychiatric diagnoses. And I love them. I learned so much. Like I've, you know, I'm a board certified psychiatrist. And I feel like when I read those things, it really helps cement a lot of the knowledge and get me back to like understanding the basics.
In forensics, there's this idea that, well, it's true, you're writing for a layperson audience. So you have to translate medical and scientific ideas very quickly to somebody who has never learned it before. And I think that's a useful skill. And I think it's something that everyone should be able to do, not just a forensic psychiatrist. So to that end, let's jump right in. What should people know about depression?
Yeah, so I guess the first question I want to ask you is, And I'm going to ask a bunch of questions and then you can take it where you want, I guess. What is depression? What does it mean to have the diagnosis of depression? What's a diagnosis? And what is major depressive disorder? Kind of a big schmattering, but yeah, I'll let you tackle that first.
Yeah, it's definitely an area of big confusion, I would say. I think that there's this idea that depression is just one thing, and it's certainly not. In fact, I would say that depression is probably the biggest umbrella term within psychiatry that applies to the most people today, that or anxiety. And depression is just a category of a feeling state or a set of syndromes that we recognize ways to treat.
Or that it's a down mood state where people are having some kind of trouble in their lives. But it doesn't tell you actually all that much about what you should do about it or where it comes from. And on top of that, that's still the case for major depressive disorder, the DSM category. It doesn't actually tell us very much about what the problem is or how to fix it.
And that's probably why you see all of these problems out there in terms of the Big scale studies on antidepressants. Are they working or are they not? This is because we are labeling a lot of things that are probably different with the term depression. And rightfully so, because each person with depression feels depressed. But where does that come from and how does it work? That's another story.
I feel like sometimes people think that there's people with major depressive disorder and then people without major depressive disorder and that there's – if we were to scan your brain, we'd be able to find that people with major depressive disorder have some problem in this specific area. Or, you know, the pharmaceutical companies kind of told us if we were to do the neurochemical analysis that we would find that people with depression have lowered serotonin or have some sort of neurochemical difference completely different from the people who do have depression.
It's as if it's a thing that they absolutely have. What would you say is the better way to think about it?
Well, I don't know if there is a better way to think about it because we'd have to all agree as a group. But personally, what I like to think is depression, depression. What we should be calling depression as a primary problem is people who have sadness, depression or difficulty enjoying things. In some way, that's pretty persistent at least two weeks in a row or just at least half of the time over a very long period of time, at least a couple of years.
If that's something that you have and it comes with problems in your energy, motivation, sleep, appetite, all those kinds of things coming together, that's what I see personally as more of a depressive syndrome. Are there people without those other symptoms that have a type of depression? Yes, yes, but they don't necessarily respond to the standard treatments.
What do you make of having the diagnosis? I guess, what does it even mean for a patient to be given a diagnosis? Does that mean that I'm forever going to have depression? Does that mean how should I think about the fact that, you know, let's say I'm a patient who's been given the major depressive disorder diagnosis. How should I think and relate to the diagnosis itself?
I think everyone should keep in mind that even for a more specific diagnosis that isn't an umbrella term like depression is, It's important to remember that diagnosis is for medical purposes. It's just a very small way to capture a certain specific problem in your life. It doesn't explain everything about you as a person, and it still doesn't even explain your problem fully. It's just a useful shorthand to zero in on what we can focus on together in a treatment.
So that's what a diagnosis is. It's really for practical purposes. It doesn't tell us too much beyond what we can expect from treatments and what we can expect in the future. So because of that, and because depression is this umbrella term, some people will have a major depressive disorder essentially for the rest of their lives. Those are the kinds of people who do do well on some kind of medication or even multiple medications in the long term.
Some people are only going to really have one major episode of depression. And then some people are going to have minor depression here and there. There are just so many different varieties of what we can rightfully medically call depression that it's not enough to stop there. We need to have a better analysis of what's going on with you other than the depression.
Can you give us an example? So you say a better analysis, I guess, do you think of depression as something that's biochemical? Do you think of it as life circumstances? What's an example of like a better formulation that could actually help someone?
Personally, I think the biopsychosocial formulation is extra helpful when it comes to thinking about depressions. Essentially, every major, not major depression, every serious or clinically significant depression that anyone can encounter is going to be from a biological source, a psychological source, a social source, or some combination of any of those, and sometimes all three. And the trouble is to figure out which one is the major contributor or which one is the easiest to treat at a certain time.
And to also understand that if the depression is coming from multiple of these angles, not treating all of them is going to give you limited results.
Now, I have patients who feel like depression is purely biological and they just want medications and any suggestion that there's any sort of other issues that should be addressed, it's almost offensive because it's like you're ignoring the fact that this is And then I have patients on the other side that they have a clear cut biological element to their depression and their brain just automatically identifies life circumstances.
It's like, yes, I'm feeling this way, but I'm lazy and yes, I'm feeling this way. But I have this going on in my life. I guess, how do you decipher when it's, I guess, how biological is depression in general? And what would you say to those patients that think it's all biology or the patients who feel like it's all life circumstance?
I think that every depression that comes along with some major change in motivation, sleep, energy, appetite, they're all biological to some extent. But there's just different Degrees of how biological they are. I'll give a couple of examples. Let's say there might be one person whose depression is more biological. Maybe they're just so slow and so low in motivation, just can't sleep, can't remember things or concentrate, and they're irritable.
That person might Struggle in their workplace and they might struggle in their relationships. That's social, right? And then because of that, they might accumulate negative interactions and then expectations from and with other people. That's psychological. Then if you effectively treat the biological root of that, then their symptoms get better, they function better, and they stop running to as many conflicts or they navigate the conflicts better with their family, friends, loved ones, and coworkers.
Then that source of stress goes away too. So by treating the biological there, you can have a knock-on effect on the psychological or the social. On the other hand, if the social situation is the major one that is causing the depression, let's say you go through a series of bereavements, major losses of social supports in your life, sudden, unexpected, and too early. And then on top of that, you're in a Sort of abusive or maybe even fully abusive relationship.
And that's causing you day to day massive stress and you have no social support. That may cause a knock-on effect on your biology. You might be in essentially a stress response in the body that keeps you low, down, unable to sleep, and unable to be motivated. And then that in turn makes it more difficult for you to leave the bad relationship or to find new connections, social networks in your life that you can rely on in person and depend upon, right?
So then in that case, if you change the context or if you change the behaviors or the thinking, that might relieve the stress coming from the psychological and social aspects of the depression and then the biological and resolve itself. We can never really know what we're dealing with with one person until we try the treatments. That's the thing. There's no image. There's no lab test. There's no radiology, no matter what anyone tells you.
As of this time of speaking, we don't have the science for that. So the best way to tell is to go through a treatment process with a good clinician.
Now, you say a treatment process, and I think some people hear treatment and they think that you're saying we need to try different medications. And I guess what I'm hearing when you say biopsychosocial is that medications are not the only treatment for something like depression. So I guess I'm curious, how do you think of treatment for depression? What role does medications play? And I think we're all seeing...
More patients who have been on a whole host of different antidepressants and said they haven't worked, I guess. How do you think about that? A whole bunch of questions, but I do want to hear how you think about it.
Yeah, it's still very individual. I'm not going to pretend that I don't have this small subset of patients where the depression seems incredibly biological. Their lives seem to have little to no stressors. They have good family support, and they've even done well in their lives, but they may still be in a depression. And with patients like that who have the strong genetic or physiological changes of depression, I see a very quick response to simple antidepressant treatment.
Or sometimes not so simple. But what I do see is a quick response despite no change or no efforts in the psychological therapy realm and in the social context. That is a little bit more clear cut. But then you have the cases where it's not so clear cut. So what can you do about that? Well, I think you really have to work carefully over time. I'm never somebody to say never do this one particular thing.
I think it's best to do everything at once. And I do think there's some good scientific evidence to say that when we use medications, it lowers symptoms and it creates more flexibility so that people can make changes in their lives. So I always think of those three basic columns when we talk about both treatment and understanding the problem.
So I guess when you have a patient present, where do you think the role of therapy is? When do you think therapy will help? When do you think medications will help? And how do you pick which one a patient should get?
Oh, I don't pick. I always pick all of them. So I'm not really picking any of them. I recommend all of them. And so then it's up to the patient to pick. And the fact is, if you're not ready to do a particular kind of treatment, if you don't believe in it at least halfway and have some kind of trust that can work for you, your expectations, your negative expectations will stop it from working.
I know that might sound magical to some people, but I strongly believe that it's true. You can think of the placebo and the nocebo effect. The placebo effect is when you take a medication that doesn't have any real biological effect, but you still get a benefit. That's from your expectations. The nocebo effect is when you take a medication that has no biological effect, but you get a negative reaction.
That's the nocebo effect. These effects happen to even people who are aware that they're taking a placebo or a nocebo. The mind is a very powerful thing. So in the end, you have to recommend all the evidence-based treatments, and each of them are lifestyle changes, psychotherapy, talk therapy, and medication. And whatever you are able to do at the moment, that's the best treatment for you. That's what I think.
And one thing I really liked is, so you just said, if a patient doesn't believe in a treatment, it's not going to work. And I hope people don't just hear that with regards to medications. It's true for both the lifestyle and the therapy. If a patient goes into therapy thinking it's going to be a dud, it's probably going to be a dud. Now, I want to talk about, so you know, talking about how I think about the difference between medications and therapy.
So I think of I think they're probably equal in efficacy. Now, medications work a little bit faster. So we know that our standard antidepressants take about four to six weeks to work, but it takes about two weeks to kind of see an effect. But once you stop the medication, the effect stops. Now, therapy, on the other hand, takes a little bit.
We should put a little caveat on that, right? It depends on how soon you stop the medication and how much someone has made progress in the meantime.
Yes, yes. And yeah, so yeah, I'm leaving out a lot of nuance here. Now, with regards to therapy, it takes a little bit longer to work, but what we see is any of the benefits that you see from the therapy are going to last even after you That's right. Yes, because they're going to feel frustrated that they can't do the thing that they're told is going to help.
So, you know, all these things interact well with each other in that you can use medications at the same time that they're starting therapy. So this way that they start feeling better and that they're able to get more out of therapy because when someone's in such a depressed headspace that everything feels negative, everything kind of feels so difficult. Therapy kind of can stall because that negative headspace makes it so that patient's not able to have an open, flexible mind.
And so I think of there's three major pillars of treatment and all three should be being discussed in appointments. And you can't just ignore part of it. You can't just say, I'm just taking the medications and that's it. I'm completely healed.
Yeah. I think what I'd like patients to know is it's a big ask, but you do need to trust the process in order to get better. You need to be able to trust the person who you're working with and getting treatment from to be looking out for you and helping you. And you have to trust yourself to be able to engage in this process. If you focus too much on the outcome, Mm-hmm.
Mm-hmm.
Now, what are things that you see confused for depression? So, you know, a patient says they're depressed, but it might be something else going on. And what do you make when patients have tried all the treatments that, you know, they say, I've tried all the medications, I've tried all the therapy, and I'm still depressed. Nothing's worked in the past. So what are the things that can be, I guess, misdiagnosed as depression?
And then what are the reasons that patients can kind of go through the gamut and not get better?
That's a very important point when we talk about trusting the process, because if you as a patient trust the process and the clinician doesn't reevaluate and consider why the treatments aren't working, then you're going to be there for a very long time without getting better, and that's not necessarily a good thing. So it is important to consider what we physicians talk about as differential diagnosis. What are all the possible different causes that could be causing this thing that looks the same?
That is important. So I would say the major mimics for depression are substance related depression, post-traumatic stress disorder, personality disorders that have also been recently called complex trauma, And Bipolar Disorders. Those are probably the main four. That is not an order of likelihood or importance. I'm just saying the main ones off the top of my head. Do you think I've forgotten any major mimics?
Well, I think the big thing, I'd want you to, because I think personality disorders, a lot of people have a particular image of personality disorders. And I almost wish you said personality dysfunction or personality aspects that kind of can lead to depression.
Well, I thought we'd probably get into more of the details as we do each category, but those are the major categories. Are we forgetting any, do you think?
Yeah, I think the big one is medical problems. Sometimes patients have medical problems that they're not aware can be a major component of their depression. A lot of the major ones, cardiac illnesses is close. Dr. Justin Marchegiani
Yeah, I suppose in my mind, I almost package those in the same category as a substance-induced, though, of course, it's related to a medical condition. But I think it's important to also note that in my experience, even when it is apparently due to a It actually often requires simultaneous depression and medical condition treatment in order to recover most fully, most quickly, and in the long run. Personally, I suspect it's because anything that stresses you, the person, enough to produce some kind of a serious depression problem, that's some kind of a major effect on the body and its stress responses.
And so even if you remove the stress, there can still be some kind of lingering effects that respond well to medical treatment of depression.
Now, what are the low-hanging fruit that you see for patients that help them get better?
Are we still talking about substance and medical?
Yeah, yeah. So let's talk about lifestyle things. So you can throw substances, medical, lifestyle changes that you kind of see.
Right. And the substance or medical condition related depressions, and of course with all of them too, no matter what the cause of the depression is, you want to really regulate your daytime, nighttime cycle. You want to make sure that you're having good sleep hygiene and that you're protecting your sleep time and that you're not using your devices and you're avoiding blue light in the evenings. At the same time, during the daytime, you're going to try to get natural light.
You're going to try to get blue light and you're going to try to get whatever activities, socialization that you can get during the day. And for substances, alcohol and Caffeine are probably the most popular drugs, though of course certainly not the only drugs that can interfere with your natural circadian rhythm, your sleep-wake cycle.
Yeah, I think any sort of addiction has a major impact on mood. And it's sort of like if you just treat the depression without addressing whatever the addiction is, it's like a boat with a gigantic hole in it that you're trying to fill. Like it's just always, you're not But I do see the impact of addiction to patients. Addictions to technology, addictions to video games, addictions to pornography, obviously the substances, all these things play a major role in mood.
And one trap I see a lot of patients get in is they say they don't feel like they're chemically or physically addicted in that, oh, I can drink four days. I can drink two weeks in a row, but then I can go two weeks without. I did dry January a year ago, so I really don't think it's the alcohol. Now, it's not the chemical dependency as much as it is the spiral of the addictive process and the impact of, for example, alcohol we know is a depressant.
So yes, maybe it helps your depression when you take that first sip, but we know that overall it's reducing your baseline level of mood. So just because there isn't a chemical dependence on a substance doesn't mean that it's not playing a major role in terms of your mood.
I think alcohol requires a specific call out because it often feels relieving to people. But the reality is it actually messes up the sleep quality in test animals, even for a couple of weeks after one dose of alcohol. But ultimately, the issue with the addiction isn't whether or not you have a mild or severe one, or even if you can't meet diagnostic criteria for some kind of a substance use disorder or an addiction.
And it's ultimately going to deprive you Because it's going to either cause a body response, a physiological issue that worsens the depression or it's taking your energy away from things that you could otherwise be doing to be improving your life. It's essentially opportunity cost.
Yeah, when you say that, the big thing that comes to mind is marijuana. I see tons of patients who are smoking weed every day and say like, oh, no, that doesn't hurt my mood. It actually kind of helps me out a little bit. And what I see time and time again, it's very demotivating. And I see patients, they get home at 6 m. and it's like, should I go for a run?
I'm just going to hit the bowl. And then they don't go for that run and they spend the night watching Netflix. And it makes it so, like you said, they're not engaging in meaning building activities or engaging in things that do improve mood. Yeah.
Yeah. Cannabis is an interesting one because while I don't necessarily believe it has a direct impact on worsening the depression, I definitely believe, as you say, that has a direct impact in preventing recovery. And I also find that it is It's commonly used for the mimics of depression as well. I think that a lot of people use high doses of cannabis when they are dealing with a post-traumatic stress disorder, for example.
It can essentially deaden your physiological reactions and you have less of the flashbacks, vivid memories, fear response, and nightmares, for example. I also think that it serves a similar function, even if the underlying condition is different, in the personality, developmental, and so-called complex trauma presentations. So while it's not necessarily a sign that you definitely have those issues, it's important to remember that while the syndrome looks the same a lot of the time, so it can be hard to tell apart from a depression and a trauma disorder, the long-term treatment is a bit different.
And that trauma disorders respond better to trauma therapy. And that personality problems or developmental interpersonal problems respond better to changes and exercises in how you conduct your relationships and with who. And a long-term talk therapy geared towards those kinds of problems. And even if either of those with a depression respond a little bit to medications or even a lot, that's not the ultimate treatment. Just like how cannabis isn't ultimately a treatment.
Yeah, and we see all the time when I say personality or trauma downstream is the depression. And sometimes patients, you know, they don't have providers that do a thorough workup and identify that, you know, yes, there's depression, but there's also this big trauma. And until you address those upstream problems, you're going to continue to see that depression. So yes, maybe a medication will work for a month or two, but eventually it's going to poop out.
And that's what you see with a lot of patients with comorbid issues that aren't being addressed.
Yeah. What are some reasons to suspect that the depression is more downstream to a trauma problem or a developmental personality problem? I would say in most simple depression alone, not necessarily simple, even in severe cases, but if it's depression alone, it's unlikely to see a large amount of nightmares, fear response, Startle, Irritability, Anger Outbursts, and Fearful Avoidance. There's certainly avoidance and even anxious avoidance in depression, but it seems to be more likely to be a product of low motivation compared to sort of a fear of bad outcomes.
And again, that can be very hard to tell for the person going through it. Because if you're not used to looking at these things through the lens of clinical terms, you may not notice the difference. And that's why seeing a clinician who can really help you figure this kind of thing out is really important. And for the personality, developmental, complex trauma, interpersonal depressions. You have to kind of look out for where does the low feelings and bad mood mostly come from?
Is it there no matter what's happening in one's life or is it really happening more in the context of bad things happening and bad feelings between you and other people in relationships and in how you relate to yourself? And keep in mind, you can have more than one thing at once. In fact, it's entirely possible to have all these things at the same time. And we do see patients like that.
It just certainly depends on the individual case.
Now, I guess when you're talking about trauma and potentially personality factors, I'm curious for patients who have tried therapy in the past and said it wasn't helpful. What advice do you typically give to them? Do you say let's not do therapy because you had a bad experience in the past?
That's a really tricky situation, especially with the overall community scene of therapy today, which I think needs a big reform. And I wouldn't mind if we did separate courses and episodes on that, though I don't know how many people want to listen to that. I would just say that any effective therapy really needs you, the patient, to understand clearly what the problem is and for that to be accurate.
And for the therapist to understand and for you to both agree on how to solve that. So if your fundamental problem is emotional regulation and difficulties in interacting with other people, but the therapy focuses on things like you talking about your stressful situations and being validated, then that of course is not going to solve your problem. Because the therapy has not been paying attention to that problem and making it a focus.
So therapy can't just be recommended as a blanket in the same way that medication cannot be recommended as a blanket solution because they should be in some sense targeted to the person's individualized problems.
Yeah, and I think therapist skill has enormous variability. And when a patient says, you know, the therapy didn't work, the analogy I like to work is if someone says like, oh, I read a book and it didn't help. Well, what book did you read? Was it Hop on Pop or were you reading – there's such huge variation in regards to what it is that you're actually getting that just because one thing didn't work doesn't mean that a different, possibly better therapist wouldn't make an enormous difference.
Yeah. And it's also how did you read the book? Did you skim the book? Did you read it through once and leave it alone? Yeah. Did you look at each chapter and kind of analyze it, keep sort of running notes about what you were learning or what you didn't want? And unlike a book, you can ask, did you ever bring up your dissatisfactions, your confusion, your negative feelings about the book with the book, in this case being the therapist, right?
Unlike reading, a talk therapy is supposed to be an active process. And I would say the easiest way to tell if you are in a good therapy or not is how your therapist responds to you bringing up issues about being in the therapy itself. If the therapist is too defensive or too dismissive in your perception after a couple tries, you should try this more than once. With you bringing up confusion, dissatisfaction, or feelings about the therapy to the therapist, then that may be a better sign to say maybe this isn't a good fit.
Absolutely. And I guess other things that I feel like commonly come up in my appointments when I'm speaking about therapists is I think of the minimum effective dose of therapy as once per week. I see a lot of patients that they go once every two weeks or they say, you know, they're not doing good, but they're like, yeah, but I just find that when we go weekly, we don't really have anything to talk about.
So now we go once every two weeks or once a month. It Therapy isn't a process of the therapist just knowing what happened in your week and venting. There's a lot more going on. And I think to really get that process going, ideally you're going two times per week. But I think of once a week as the minimum. And then they journal about it. There's usually a lot going on in between.
It's not just this sterile hour of venting to a person.
Yeah, I guess I would take issue with the twice a week recommendation outside of meccas of psychoanalysis like New York City.
But I do agree with the
minimum one hour. Minimum one hour and, of course, is interactive process. It's a process of self-reflection and it's a process that you should be taking outside of your life. And if you find that you have nothing to talk about after one week, that's the thing to talk about, the perception that you have nothing to talk about. But now we're getting too much into therapy and not about depression.
One other really low-hanging fruit, and I wish I kind of said it with sleep, I think sunlight in the morning. One recommendation that I've seen make a big difference is telling patients to get 15 minutes of sunlight within the first hour of them waking up. Now, why that's so helpful, I think it's a mood booster. I think the sun is a mood booster on its own. And also it really helps regulate your circadian rhythm.
And we know that depression really throws off your circadian rhythm. And especially for bipolar patients, that circadian rhythm gets thrown off. But 15 minutes of sunlight in the morning can kind of help people feel a little bit better in the morning, can help regulate sleep. It's a really helpful thing to do every day. And there's one other lifestyle thing that I think is really important that I see more and more commonly is phone and social media addiction.
And I think social media can have negative effects because it can feel like you're engaging in socialization without the... Important feelings that you get from socialization. And I see lots of patients that are addicted to their phones. Their phones almost provide like a medicinal quality of helping them distract how they're feeling. But that behavioral loop I was kind of talking about, engaging in activities that make you feel worse so that you're more likely to engage in those activities can kind of, I see that loop happening a lot.
So I think trying to use your phone less, trying to use your phone more mindfully is one of those low-hanging fruits that can make a big difference.
I think we should talk about bipolar disorder.
Yeah. Okay. So why don't you talk quickly about bipolar disorder?
This is a very important one. It's very easy, I think, for people to go many, many years with medical and psychological treatment and not get better because what they actually have is something closer to a bipolar disorder. This can be the case for even people who never actually meet DSM criteria for a full bipolar two or bipolar one. Because unfortunately, there just seems to be a set of people who don't respond very well to the typical first-line antidepressant treatments, or they may respond temporarily, and overall, it may cause them to have more episodes of depression over the long run.
And how can you tell? Well, you need a skilled clinician that has experience treating a wide range of different mood disorders. And what the solution is, is usually mood stabilizers. Mood stabilizers or, when necessary, a second-generation antipsychotic known to be effective in a bipolar disorder for bipolar depression.
Absolutely. Now, things that point in the direction of a bipolar illness, the biggest one is family history. So if there's a sprawling family history of bipolar disorder, it really raises the chances of what we call bipolarity. And I think that's kind of an important distinction you made. You can have a bipolar-type depression and never have had the typical signs of bipolar or hypomanic or whoremanic episode. Now...
I want to circle back. We were starting to talk about things that help for depression and we talked about the importance of addressing substances first, the importance of addressing trauma. You briefly mentioned sleep and what I wanted to talk about is I actually think it's sleep and the bigger category that I think of is patterns and stability. And what I think is super important for every person to work on, and this is true of every diagnosis, but I find it's really helpful for mood disorders, is building a stability in their life so that their days have particular patterns.
And things that are really helpful is waking up at the same time every day. When you wake up, having a little bit of a routine in the morning to kind of get things going. Eating at the same time every day. Exercising at similar times every day. Socializing at similar times every day. Or just socializing at regular intervals. So you're not seeing friends once every two months. And I think for mood disorders, trying to really build that stability in your life.
And I think sleep is one of the biggest ones to start on because sleep has a very bi-directional relationship with mood in that when people start to get depressed, oftentimes we see their sleep fall off. And as their sleep gets worse, their depression gets worse. And sometimes you need to address the sleep on its own, but oftentimes we see that bi-directionality of they feel worse, they sleep worse, they feel worse, and on and on and on.
That's right. Of course, a lot of people miss that the waking period is probably the most important behavioral aspect of sleep. A lot of people psychologically reasonably focus on the falling asleep part because that's the part that maybe feels worse for a lot of people. But enforcing a steady wake time every single morning, no matter what, And having some kind of morning activity, rituals, things that you do, that's very helpful.
And that does tie into the concept of behavioral activation, which is evidence-based treatment for depression, where the fact of simply, in short, setting goals and meeting them, even if they're small, and getting some movement in the body Getting some activity in there. Doing that on a regular basis can help boost and treat the depression. Not boost the depression, boost the mood. Now, there is one thing to note here, personally.
I say that if someone is having consistent early awakening, then that's really a sign that there's something a little more medical. Right? That could be caused by PTSD, for example, that could be caused by a sleep disorder, or it can simply be caused by the depression itself, early awakening. If you're early, if you have early awakening frequently enough that enforcing a steady wake time isn't going to help your sleep wake cycle, then that's when medications are probably indicated.
Absolutely. Now, I do want to go into a little bit more detail about behavioral activation because I do think it's probably the simplest, most important thing you can teach in a short period of time. So the concept, as you mentioned, is you really want to build a life of meaning and you want to engage in activities that make you feel better. And I like to talk a lot about feedback loops because I think feedback loops are an important part of depression.
When someone starts to feel bad... It makes it so that it's much harder to motivate and it's much harder to get things done and it's much harder to go do things. So people start feeling worse. So they stop engaging in activities that they find meaningful. And then because they're not engaging in those activities, they feel worse. So it makes them less likely to engage in those activities.
And... The big thing to work around that is rather a lot of patients wait until they feel better to start engaging in things that they like doing. So they say, you know, the common scenario I see is someone gets home at 5 m. and they say, I'm going to go for a run at 7 m. You know, once I start kind of feeling better and I feel motivated.
So they sit and they eat dinner and then dinner after dinner, they go like, I'm full, you know, I'll wait till I digest and I feel motivated to run. And then it's nine o'clock and it's like, you know what, I just kind of want to wind down. Essentially, they wait to get motivated and the motivation never comes. And what I try to teach patients is I want to almost flip the script.
I want you to say, I'm going to engage in this activity so that I feel better. Because the automatic thing is, until I feel better, I'm not going to engage in this activity. And I like when we pick something that we know makes the person feel better. And they start developing the mindset of, until I go for a run, I'm not going to feel better. So it's deciding to act independent of the immediate desire to kind of go do those activities.
And what you see is as you engage in those activities, They start making you feel better so that you're more likely to engage in those activities. And the most important thing, I think, is picking something that you really want to be engaging with that you know makes you feel better and set a really specific goal. So whether it's I want to go for a walk outside three times per week and using that as the thing is I'm going to schedule it.
I'm going to put it in my calendar and I'm going to try to engage in it regardless of how I feel in that moment about actually engaging in that activity.
And I would even talk about now more severe cases because those goals may even be too much for severe cases. The real point of this is to set goals however small and accomplish them. And if you find that you're not accomplishing them, make the goals even smaller because we don't want to produce even more stress over not setting goals. And a lot of people who are depressed are already overly self-critical.
So even if it's having made the goal to be the goal, that's better than not making a goal at all. If you make a goal and you fail, that's better than not making a goal at all. Focus on the process rather than the outcome.
So, you know, talking about things that we feel like can make a big difference, we talked about addressing substance use, addressing sleep, addressing stability and having some patterns in your life, behavioral activation. Are there any other really big ones that you think are important?
I do think that the lessons of interpersonal psychotherapy are very important, that building a A social network, social supports, people that you can rely on and talk to about your feelings, your thoughts, and your wishes. That's actually a very important aspect to long-term recovery and depression. Now, this can be particularly difficult if you're not someone who has had supportive social contact throughout your life or your development.
Then, unfortunately, that's going to require you to learn how to build and have new ones. And this may even be in the context of a support group, a community support group. This is kind of similar to what you're talking about. Some people have never really had any major activities that they were able to get enjoyment out of, right? If that's the case, then you have to sort of decide on your values, what you want, the kind of life you want to live, and the kind of relationships you want to have, and slowly build towards that.
Yeah, I think a sense of community is huge. I think, you know, talking about small interventions that I've seen make a big difference. I've seen people reconnect with old friends, their college friends, reconnect with their church, reconnect with Reconnect with their meditation center. Reconnect with a sports group. I had a patient that we were spitting our wheels for a long time and then they found a basketball team that they would play with throughout the year.
And all of a sudden they were feeling better and all these problems that kind of had been there kind of melted away because they felt like they were in a group that belonged and they would text a lot. So really engaging in the community, engaging in friendships makes a really big difference. Now let's move on from those sort of things. A few last questions. I guess, how do you feel like, let's say there's someone who doesn't have access to therapy or has an insurance that makes it so they're scared of kind of going through that hurdle of finding a therapist.
How can patients get help without a provider or without a therapist? Yeah.
You know, if it's still at all possible for you, I think it's something that you should try to get, at least a little bit. Because even if it doesn't seem to help, I think the act of speaking about your problems with somebody, anybody, your feelings, and then interrogating why it's not working, that is so valuable, even in the short term. But, of course, we live in reality, and it may not be practical for your schedule, for your economics, to get therapy.
In those cases, I recommend that you really hit the bricks in terms of socialization, lifestyle changes and taking medication if you can't get therapy and you have depression. And then on top of that, I do recommend some workbooks. I think Feeling Great, it used to be called Feeling Good, was a very good general workbook. Go on.
Oh, no. So it got the upgrade from feeling good to feeling great on the updated edition.
Yeah, that's right. The author is David Burns. He's a classic teacher in cognitive behavioral therapy. You know, no matter your feelings about cognitive behavioral therapy, there are some very useful things to learn there.
Yeah, the two big books that I always recommend is Feeling Great and then The Happiness Trap. And I think of Feeling Great, the big... There's a lot in it, but the big thing is paying attention to thoughts and essentially... Some people think of CBT as they say like, oh, I don't want to just be positive all the time. And what I see, especially as a clinician, is depression isn't that you're more realistic.
Depression is a huge negative bias. And when you hear patients talk about things, There's a rose-colored glasses of negativity. And CBT deals with addressing those negative thoughts that create the worst feelings. And it's not just positive thinking. It's actually much more accurate thinking. Now, the happiness trap uses more of acceptance and commitment therapy. I... They're very different approaches. I do find for people who are less workbook oriented or a little bit less homework oriented, I do like the ACT approach.
So that's the happiness trap.
You know, on the topic of what you say just now, I think it's very important to emphasize that it's oversimplification, but the human mind is essentially a machine that can program itself. The kinds of thoughts that you say to yourself that basically creates that reality for yourself. So that's why it is important to find new settings and new people if you don't have those safe and healthy settings and people and activities in order to begin to think and feel in different and new ways in order to get better.
And to that end, I don't only recommend Feeling Great, aka Feeling Good from David Burns. I also recommend Get Out of Your Mind and Into Your Life, which is from the ACT therapy original folks. Though, to be honest, I do find the one for adults to be a little intense and dry. And don't be afraid to start with get out of your mind and into your life for teens, which is kind of cute if you're an adult to work through because it's geared towards teens, but it has basically the same content and the same skills.
Yeah, awesome. And the author of that book, I think, wrote the forward on the happiness trap. So they're very similar content. Yeah. And then you become what you believe about yourself. I think you're kind of mentioning the thoughts that you kind of have. If you constantly believe these things, you will make them true. And that's good. That's true if it's a positive thing or a negative thing.
You can't think positively out of a medical condition alone, but the thinking negatively is not helping. That's the short version.
Well, now I want to switch gears. We talked a little bit about how to think about having a diagnosis. Now, I'm curious, what are the risks and or benefits of saying, I'm too depressed, I'm depressed, I have depression, I have major depressive disorder?
Well, that's actually, I think, completely related and not a change of the gears. We're talking again about how are you programming your expectations of the world and yourself? What kind of thoughts are you having? And are they impacting your progress in your life and in getting better? It may be factually true that you are depressed. It may even be factually true that you're too depressed. But are those useful and productive thoughts?
That's sort of a different story. In treatment, you can generally consider that the things that you consider to be a part of yourself, especially if it's an unchangeable part of yourself, those are things that are not going to respond as much to treatment. If you can begin to conceptualize a problem that you have as something that isn't fundamentally part of who you are, Isn't fundamentally something that you have to have or do, then you stand to have more hope of changing and improving.
Of course, in classical medical teaching, this is the difference between symptoms and problems are ego syntonic or ego dystonic. It's a lot easier said than done, but it's still important. Not identifying too much of your illness or your symptoms. That's an important step and a helpful step, in my opinion, to getting better.
Yeah. And, you know, we're talking about Feeling Great. In the Feeling Great book, they talk a lot about the importance of addressing resistance. And he's got a kind of a very positive way he talks about it. And he says, like, what does happen? Yeah. Yeah. Yeah.
Yes. There's a concept in mostly forensics, but not just forensics, called a compensation neurosis. We've seen that when somebody is undergoing litigation or if they stand to receive some kind of benefits from a case or from anything because of the illness that they have, they're much less likely to get better. And I strongly believe that this happens unconsciously in many cases. It's not that people are pretending to be sick so that they can get a big payout or so that they can get disability payments.
I think genuinely a lot of people unconsciously will resist getting better because there's a lot of things that are scary or unknown about getting better. Or if we get better, we have to face the failures or regrets of the past. And that's not an easy thing. But of course, that's why it's important to have people that you can trust, talk to, and express your feelings to, both in your life and in the talk therapy.
Yeah, and I, you know, we talked a little bit earlier about behavioral activation. And I see, you know, there is a danger with depression. I do see, you know, I see people who say like, oh, I didn't go see my friends because I was feeling too depressed to go. And I have also heard the flip side of when I see a depression treatment go really, really well, what they say is, you know, whenever I'm feeling like this, I always like, I'm like, oh, I hate spending time with my friends.
This one friend is always a jerk to me. I always get in a fight with this person. You know, we don't have that much fun. And then if you talk to them afterwards, it's like, oh, I'm actually really happy I went. I always love seeing them. I don't, you know, I always... Like, don't ever want to go, but then when I do, I have so much fun.
And the big difference that I see with a productive treatment and treatment that isn't going that well is when a patient starts using their And I hear patients say like, oh, I need to run three times a week. Otherwise, I'm susceptible to slipping into depression. I know that on Fridays, I always want to just sit home, order pizza, and watch Netflix, but I know I need to go see my friends because it's really important for me feeling better.
People have different relationships with how they Yeah. And I think it's important to think of, how do you relate to your diagnosis? When you say, I have depression, what do you mean by it? And what are the things that it makes it so that you need to take care of? And what are the things that you actually avoid because of it?
Yeah, ultimately, we need to interrogate and consider and be realistic about Do the things I do help me or do they hold me back? Are they leading me forward or are they holding me back? And that's not a decision that we should only make alone. I think it's impossible for us to know individually all of reality. And by having other people in our lives, both professional and personal, that we can check with, that's a very important part of recovery and maintaining recovery.
Yeah, and this actually leads to one of my final questions that I had. For patients who have been diagnosed with depression, how should they talk to their family about it? How should they talk to their partner about it? How should they talk to their friends about it, their coworkers?
Yeah, it's funny. It's a really important question, but there's also not one answer. And I think that it depends on the quality of your family, the quality of your partner, and the quality of your friends. You know, a medical condition is a private matter. But at the same time, I would say that it's something that ideally we should feel comfortable seeking help from and being at least somewhat open and clear with the people who are closest to us.
So ideally, by sharing our troubles and talking about the treatment plan, we get encouragement and not judgment, and we get support and not people getting in our way. And if sharing that information is causing some kind of stress or backslide in your treatment process, then maybe that's not the best thing. But that may also require some hard analysis about whether or not it's a healthy relationship that you're in.
Yeah, I think it's impossible for, you know, because I've had patients ask me that question of should I tell this person and this person? And the answer is no one can tell you what the right or wrong thing is. And the analogy I like to think of is what's important is that these zippers on the inside, you know, that you get to control. Who it is that you tell, what you tell, and how vulnerable you want to be with that person.
And for some people, I have a lot of patients with parents with regressive views that if They found out that they were taking medications, they would disown them. It's very different than your partner who feels like you're distant and aloof and not sure what's going on. And the right answer is very individual. And, you know, I see patients who don't share enough and they don't have enough people that they can feel vulnerable and tell them about their internal experience.
And then I see patients who kind of doth profess too much, whatever that is, like they're telling their coworkers and they're telling their boss and they're talking to it. I was at Starbucks the other day and the lady was like, oh, I have depression. I'm not saying that's right or wrong, but, you know, make sure the zipper's on the inside.
Yeah, I think ultimately it's how likely is it going to help you? Because I have to say, even taking one medication on a daily basis is a lot harder than people give it credit for, no matter what that medication is for. And when it comes to taking medication that has something to do So if sharing with family or friends can help people support you in remembering or keeping up with things like medications, therapy visits or your activities, then I'm all for it.
And in some cases, I would even say it's medically necessary. But of course, again, it's an individual situation sort of thing.
Absolutely. All right, I see we're close to an hour. Is there any other burning things you want to get out? Any burning things you want to tell the world or things that, you know, is really big that we haven't talked about?
Not exactly. Not exactly. I would just say life isn't so simple and your situation may not have been covered by this limited information. The best way to figure out what's going on is to seek treatment locally and to connect with and test your understanding of reality with the people around you.
Absolutely. All right. Well, I think we can wrap it up here.
All right. Well, until next time.