What we’ve said about Major depressive disorder

“depression is probably the biggest umbrella term within psychiatry that applies to the most people today, that or anxiety”

“Do we mean true, recurrent, Biological type major depressive disorder, the cousin to bipolar disorder, or do we mean dime stored depression from personality and stressors that happens to meet major depressive episode criteria”

“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”

“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”

“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”

“In normal grief you're sad because something happened to you and depression you think the problems inside in normal sadness you have a sense that this will pass in depression one of the worst things about a clinical depression is it feels endless”

“When you have a bucket as big as depression, as big as anxiety, there's going to be 20% are going to have major rage problems. 80% won't have major rage problems. As you said, it washes out because, you know, it is actually working for some”

“his manic depressive illness, today we would actually put both major depressive disorder recurrent and bipolar disorders under manic depressive illness, because for him, it was not the polarity of the episodes that mattered. It was the chronicity and the recurrence”

“I would add severe recurrent unipolar depression, what Max Fink and Edward Shorter have called melancholia, which is a similar construct. Depressive neurosis or neurotic depression, chronic depression, Low-grade depression that seems to be a part of the patient's personality”

“the hallmarks are different than normal self. Almost all day, almost every day, two weeks in a row and changes in any of the following, but distinctly energy, sleep, appetite. Okay. More of a wholesale change in biological functioning than a subjective state of depression”

“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”

“the more I see that there's a big gap between when patients say they're depressed and when they have major depressive episodes”

“this is the absolute worst thing you can do, is say, were you depressed and use that as your screener for depression. And what I recommend is using something like the Madras. So the Madras has questions that are linked to the DSM criteria”

“Then I say, well, how often have you had that throughout your life? How long has it usually lasted? How much time do you get in between? Have you ever felt fully free of the depression for at least a month since the start? How long”

“Are you the type of person who can identify particular episodes? Or is it this kind of thing that's kind of been there all your life and doesn't really fluctuate? And that to me is a helpful screener for major depressive disorder versus dysthymia or another condition”

“At that point, I still ask if the depression has never really gone away. Are there times where nonetheless it's consistently worse in a persistent way for at least two weeks in a row? And if so, how long does that usually last”

“whenever there's depression, early morning awakening, I forget what I read, but I think it's like the most specific symptom for depression. When a patient wakes up at 3 a.m. for a few nights in a row”

“People are depressed. They get decreased deep sleep, uh, increased light sleep, increased REM percentage”

“a 40-year-old woman who comes in with her first episode of major depression all day, every day, low mood, low motivation, early awakenings, leaden paralysis. You put that lady on a little Zoloft, she's going to start responding right away”

“someone with a classical, more biological depression... You know, the kind that can happen to people in episodes lasting at least two weeks in a row. And even if their life is pretty much going OK. They look different”

“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”

“this is why I think that the primary mimic of PTSD, the thing that PTSD gets misdiagnosed as the most is persistent depression or major depression”

“people with PTSD, they show up, they tell you they're depressed, they tell you they're stuck in negative emotions. They tell you they're not doing the same things they used to do. They don't look depressed a lot of the time, okay”

“if it's depression alone, it's unlikely to see a large amount of nightmares, fear response, Startle, Irritability, Anger Outbursts, and Fearful Avoidance”

“I simply asked, what kind of problems were you having at that time in the period leading up to the offense? And so I had her talk about her day”

“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”

“Depression of personality is what I call it. Really should not be overlooked because it very much looks like and even feels like to the patient major depression. But you can tell you based on the life course and the onset and various other factors that it's not quite the same”

“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”

“it's interesting to find that the majority of people with a true bipolar disorder, most of them, mostly experience depression, especially major depression and usually major depression in episodic way, discrete episodes, multiple across a lifetime”

“if you are able to detect a episodic and recurrent major depressive picture, that starts to raise the possibility that there is a bipolar spectrum disorder or at least a possibility of mixed depression or refractory or biological seeming depression rather than depression secondary to life circumstances or personality”

“The next question I have is not about mania or hapomania. The next topic is history of major depressive episodes”

“there are varieties of major depression, again, not from personality, not from trauma, not from stress, but any more Biological major depressive episodes can be agitated depressions where you have severe insomnias, you have just psychomotor agitation”

“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”

“Somebody with a bipolar disorder generally can become agitated or worsen if you give SRI, serotonin reuptake inhibitor, So do be careful about that”

“he, he says half jokingly that when you see, um, MDD, GAD and ADHD in the same patient, that's a cyclothymia. Maybe that's true 50% of the time. I don't know”

“any depressive disorder here, all the way from dysthymia to major depressive disorder, psychotic features, any of these can cause problems with concentration and staying on task. It's in the core criteria”

“Not only can your attention be distracted by persistent negative thoughts, people can have psychomotor and cognitive slowing. Right. Slow thinking, talking, moving. They can have psychomotor agitation”

“what you're really seeing is those depressive symptoms, is that withdrawal, is that shutdown of the seeking and go out and enjoy enjoyment and activities. And you don't hear in the longitudinal history”

“What would be the stereotypical example of somebody presenting with inattention based on the mood disorder? You wouldn't hear really of any significant problems until at least adolescence”

“a lot of what is popularly referred to as symptoms of ADHD on social media, while, yes, present in many people with true ADHD, generally speaking, what they're talking about, that symptom cluster is better attributed to depressive disorders, trauma disorders and personality”

“a lot of these times the conditions are comorbid, right? Some level of ADHD traits or even disorder are interacting with anxiety, depression, stress, something”

“If I think that there is possible depressive and there's no bipolar and there is some ADHD stuff and they agree, I'll do a trial of Wellbutrin”

“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”

“Psychotherapy is the treatment for unipolar depression, and people ought to get trials of three different Psychotherapies before they get a first trial of an antidepressant”

“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”

“So by treating the biological there, you can have a knock-on effect on the psychological or the social”

“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”

“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”

“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”

“If you're treating major depression and you're on your third medication in a row with no remission, reconsider your diagnosis”

“you do see providers just try medication, medication, medication, medication. People need to be doing something. They need to have a purpose in life. They need to be – one of the most important things is having small goals and achieving them”

“landmark study where they tested several arms of treatment for depression and would either switch or augment depending on lack of response. And there was even an arm of psychotherapy as well. So sort of a lot of our kind of standard practice for treatment of major depression is at least inspired from that study”

“I'll never pick medications that will cause weight gain or appetite increase if I can help it. and I try to minimize side effects. That's kind of rule one. And then rule two is most efficacious”

“In my opinion, first line medications for antidepressants, I'm thinking of escitalopram, sertraline, mirtazapine, bupropion. I think those are all reasonable first choices depending on patient profile. I very, very, very rarely deviate from those four”

“you can titrate it on multiple steps. Eight steps to the FDA maximum. Pretty useful. Secondly, just works. Works pretty great. Third, does not have much in the way of med-med interactions”

“it only has four titration steps, unfortunately, which I don't like. I like to have more steps. I think that works psychologically. Physiologically”

“if your patient tends to miss doses, skip doses, great medication. You can just give a higher dose and they skip a few doses a week. Long half-life still gives you effective serum level”

“its efficacy, it works quickly, you know, and it's a Sleeper on top of being an antidepressant class medication. You get a lot of bang for your buck there. All in one tablet. Easy to dose. There's a long-acting form and a short-acting form”

“Famously, the worst withdrawal syndrome out of all the antidepressants. I've even seen an elderly person get medically hospitalized once because of the withdrawal from venlafaxine. So it works well, but just be careful. You want to taper it slowly”

“Love to throw this on on almost everyone who doesn't respond to just one medication. A-class, certainly A-class as well. Great medication, can give you a pep in your step”

“It is probably the number one augmenting agent at a low dose for depression, proper depression when added to an antidepressant, but by itself doesn't really help in bipolar depression”

“a lot of antipsychotics are depressogenic. They can lead patients to depression and long-term aren't great. A lot of these medications come with really bad side effects, really bad metabolic effects. There's risks of... of EPS, tardive dyskinesia, typically not the lower doses”

“Low-dose trazodone is not a small antidepressant. So it is one of those medications that you need to get it to the higher doses”

“Additionally, if they're not very sensitive to trazodone, they can take a very high dose. I can take it up to 200 plus, and now it's an antidepressant too”

“you don't use something that's not indicated just because the side effect profile matches the side effect profile that you want. For patients with emotional dysregulation and reporting depression, I do see it helpful. I don't see it helpful in MDD proper”

“SSRIs in people without major depressive disorder are actually disruptive to sleep. Same thing with low-dose BuSpar. Basically, the serotonin mechanism will suppress REM sleep and also cause more nighttime awakenings”

“lithium has evidence for unipolar depression as an augmenting agent, right? So there's probably some, in my opinion, there's probably some percentage of people that have just a really clear-cut unipolar but severe depression, that there's something in there that's a little bit more bipolar”

“But since learning about that, whenever I've heard a patient has had recurrent mood episodes and I see a lot of the previous medication trials haven't worked, I really make sure that there's been a mood stabilizer trial at some point”

“Europe is much more willing to give lithium as adjunct for the treatment of what seems to be a unipolar depression than we are, you know, and I think they may be onto something there”

“Where I think it's least appreciated and most valuable is in the middle of this mood spectrum, where sometimes this might be along with modified social rhythm therapy, for example, or Lamotrigine”

“When I'm consenting somebody for ECT for major depressive disorder, I expect them to do 12 treatments. We try to do three treatments a week”

“I'm a fan of using the PHQ-9 not as a screener, but rather to track symptoms because it covers a lot of the symptoms. It's shorter and easier to administer than something like the ham. or the BEC, and I can do it in a visit”

“I think probiotics, omega-3, and methylfolate are where we have some of the best evidence for depression”

“there are about, I remember about 30 controlled trials of omega-3 and depression. And they only show a benefit if we look at the ones that used high levels of EPA. The analyses are now recommending that it have at least twice as much EPA as DHA”

“The proper dose is 15 milligrams a day, which is available through several products on Amazon for just about $5 a month. So your patients can now afford it where it used to be difficult”

“we see a lot of dysbiosis, that's problems in the gut microbiome in people with depression. So you probably don't need to test for that. You can probably assume that it's there and give a probiotic. Probiotics have good studies to treat depression”

“we peeled away the studies dividing them based on whether they were actually supplementing a deficit or just giving vitamin D willy-nilly. And it looked like there is a real benefit if the patient is low in vitamin D”

“So we're talking about a larger effect, a big effect for this one. And is it addressing a deficit model? That was the whole point of seasonal depression is there's a deficit of morning light. So you have to give this in the morning, not the afternoon”

“With estrogen-based, we have evidence that hormone replacement therapy improves depression when added to an antidepressant. These are small trials, and most of them used a patch”

“all these trials were done on people with verified low testosterone. So we're not talking about going beyond the normal, but we can tell people if they have verified low levels of testosterone and they have depression, they might want to talk with their PCP about the risks and benefits”

“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”

“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”

“I don't just want them sleeping more. I want them starting to get into a habit of sleeping at night and being active during the day. I try to build that into the behavioral activation component and making sure that they're well-rested”

“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”

“you have to essentially act like a non-depressed person, even if it feels bad, even if you don't enjoy it, to the extent that you can handle it, on top of the medications to really speed the recovery from a depressive episode”

“Exercise helps mood. It helps anxiety. It helps sleep. It just is such a crucial pillar of your health”

“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”

“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 think a really helpful thing to understand is that work is a really stabilizing force in people's life”

“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”

“Next, major depressive disorder. Similarly, I give it an A-. I think it's something that I think is really important”

“the two big books that I always recommend is Feeling Great and then The Happiness Trap”

“I don't usually recommend a workbook unless I have gotten a good idea diagnostically of what's going on with a patient. I still need to have a pretty good working idea of what their core problem is”

“it's like a boat with a gigantic hole in it that you're trying to fill”

“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”

“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”

“they are symptomatic treatments that create habits, build tolerance, and stop working. They're not fundamental treatments of the underlying condition, so much as they are that they're drugs that help people feel better temporarily”

“What you feel on a stim, on meth or cocaine or speed, which is what Adderall is, is an intoxicant effect. That is the euphoria and energy burst, and you will build tolerance to that”

“it doesn't treat depression in the long term. And what I've seen with so many patients who have ADHD plus depression is you're You're not treating the depression and you'll see irritability creep up. You'll see somatic symptoms creep up”

“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”

“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”

“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”

“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”

“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”

“our minds are meaning making machines and our minds automatically find things to cling to to make sense of our experiences”

“if you are the it guy and you never talk to anybody in person and you work from home You might not be as impaired by your lack of showering. But if you're in sales, that's a real impairment”