Reaching Out For Help With Depression

MAUREEN CAVANAUGH: This is KPBS Midday Edition, I am Maureen Cavanaugh. The death of comedian Robin Williams is teaching us a lot about the causes of depression. Sometimes diseases like Parkinson's can cause chemical imbalances in the brain. Major surgeries can also cause depression. We learned that depression affects almost one in fifteen Americans, and most people who struggle with depression do not get the care that they need. Joining me to expand on our conversation about treating depression are my guests, Doctor Steven Ornish, David Peters, and Graeme Cowan. Thank you for coming in. There is not one surefire treatment for everyone struggling with depression. How do you do determine what kind of treatment is right for a patient? STEVEN ORNISH: Research shows the most effective treatment for depression is a combination of psychotherapy and antidepressant medication. The most important thing is to make a correct diagnosis. As you mentioned, there often medical costs that can cause depression. 40% of patients with Parkinson's have depression. Patients who suffer from low thyroid or hyperthyroid can have depression. It's important to make a diagnosis first. The most qualified to make diagnoses are psychiatrists. Therefore years of college, four years of medical school, four years of mental health residency training in psychiatry, and they are in a unique position to do a full evaluation to determine the appropriate diagnosis, make sure it is not due to medication or underlying medical conditions, and initiate antidepressant treatment and or psychotherapy. For those who do not do psychotherapy, they can often they can make the appropriate referrals to a psychotherapist, psychologist, and MFT, for additional treatment to complement antidepressant treatment. MAUREEN CAVANAUGH: Many people who end up with restrictions for antidepressants have been given that prescription by the primary care doctor. Many of them, if not most, don't go on to see a psychiatrist. Is that a problem? STEVEN ORNISH: It's a problem, but primary care physicians are also trained to treat depression. Primary care physicians, pediatricians, gynecologist, they all have training in medical school and residency in the diagnosis of and treatment of depression. Primary care physicians canned initiate antidepressant medications, but they can also make a referral to a psychiatrist, psychologist or psychotherapist to complement the treatment of the antidepressant treatment. I don't see it as a problem, but if you are seeing a primary care physician with treatment for a antidepressants, make sure you have an appropriate medical workup, and ask a psychiatrist or counselor to complement the treatment of depression. MAUREEN CAVANAUGH: David Peters, you are a psychologist and you cannot prescribe drugs, but are many patients referred to you after being prescribed depression medication? DAVID PETERS: Let me do a little correction, I am a licensed family therapist, not a psychologist. But I am licensed to provide psychotherapy. Yes, it will be referred to be from a psychiatrist or general practitioner, and in the best of circumstances, I therapist works with a medical doctor or psychiatrist who is prescribing to coordinate treatment. It is not the norm, I find a lot of therapists not calling the psychiatrists, I find a lot of doctors not communicating with therapists, and you are getting second-class treatment. Really you want an integrated approach where the professionals are working together, and I find that you can find your favorite psychiatrist to work with, and they do have better training in psychotropic medications than general practitioners, and we can get a lot more effective treatment that way. MAUREEN CAVANAUGH: When a person is seeking help with depression, how do you determine how serious the situation is? DAVID PETERS: There are standard questions that you ask, about the history of depression on a 1 to 10 scale. I certainly ask do you experience a lot of emotional pain? I ask questions directly, have you ever thought of hurting yourself or contemplated suicide? If someone has thought about it, a lot of people who have been depressed have said they would rather not be here, I would rather be dead. But they don't really think of going ahead with it. But if they say yes, I have thought about how, and I asked him how, they think of pills, razor blades, jumping off a bridge or whatever. If they know how they would do it and have actually thought about how they would work on that plan, and they may be added immediate risk and might need to be hospitalized for psychiatric hospital for a few days to make sure they're safe. I also want to call relatives at that time and make sure that someone is staying close so that when someone is at the worst part of depression and actually considering suicide that we have enough support to prevent that act. So many people have been suicidal a month, or two, or a year later they are glad they did not go through that, because they can feel alive again after treatment. MAUREEN CAVANAUGH: Graeme, in your book Back from the Brink you surveyed over 4000 people who have lived with depression or bipolar disorder. What did they tell you about effective treatment for them? GRAEME COWAN: It was very interesting, I had some frustration when I was going through found depression. Mine was the worst depression my psychiatrist had ever treated, it lasted for five years, I tried twenty-three different medications, I had shock therapy, and I asked people, what works for you and what would you do differently? The most important part of the recovery was having compassionate and emotional support. Those from loved ones, were collies, support groups, and also from mental health professionals. They said that the most important thing was actual compassion they got rather than the actual treatment. The next thing was getting to the right mental health professionals. Unfortunately, not all, especially prime physicians, have good skills in diagnosing an illness. For example, there are minor differences between something like depressional bipolar II, the medication is different. It's important that they see mental health savvy primary physicians in the first place who can be the gateway to the psychologist and psychiatrist. The third thing was exercise. Exercise thirty minutes with a brisk walking was considered paramount to recovery. The Mayo Clinic shows a thirty minute brisk walk improves your mood up to twelve hours later. Finally, fulfilling work. When people are at home, not working and isolated, that is devastating for them. Even if they cannot do paid work, to be able to volunteer. Those are the four key things that came from the research. MAUREEN CAVANAUGH: Doctor Ornish, when you are treating a patient for depression, how long do you give a certain treatment to work? There are number of different medications that you can give to a patient, if you prescribe a certain drug, how long should it be before the patient gets good results before you think about revaluing what is going on? STEVEN ORNISH: The medications are generally well tolerated with minimal side effects. Usually when I prescribe medication, it usually takes several weeks before they kick in. And then you often do not get the full response for several months. If I prescribing medication, if I see no benefit within 30 to 45 days, I will ask if this is the right medication or should I consider changing it. Sometimes you'll see a benefit and the benefit will continue for several months. It is important to be patient and not prematurely stop the medication. Other times, you'll get a partial response to the medication in which case you may adjust the dose or augment it with the other medications, such as lithium, which is good for bipolar disorder as well as depression. It's more of an art than a science, and that is with the art of medicine comes in. MAUREEN CAVANAUGH: I'm wondering, what kind of factor do health insurance plans play in this? For many plans, I understand the number of therapeutic visits to a psychiatrist or therapist are limited, where the number of medications that you can get and the different ascriptions are not necessarily limited by that health plan. Is that a factor you run into in your practice? STEVEN ORNISH: It can be a factor, but now that the parity laws have changed, people have much more access to mental health care, insurance company so much more likely to cover it than they have in the past if you do run out of visits with a psychiatrist, and a person is stable, sometimes then you can have the primary care physician's new medication and monitoring that. There are also county clinics where patients can get treatment if they do not have resources to see someone privately. There are a lot of different options for those in need of treatment. Generally the economics are not a barrier, particularly in San Diego, whether such a good county system available. MAUREEN CAVANAUGH: Graeme, I assume you've been on some of these medications? GRAEME COWAN: I've been through twenty-three different commendations. MAUREEN CAVANAUGH: What is it like? GRAEME COWAN: It's horrendous. You keep going, in my case, as I said I had profound depression which my psychiatrist said was the worst he had worked with. It's really difficult to wait for something to happen. I think that's why it's so important to take action with other things as well, like exercise, by some strategies, sharing what is going on with those around you, not keeping it private. There's a large stigma, and I think if one can come out of the tragedy of William's death, it's that people will talk more willingly about it and ask for help, because I can tell you with 100% certainty, that you can come back from the brink, and I'm living proof. MAUREEN CAVANAUGH: David, you've been on this program for talking about alternative therapies to depression, and it sounds too easy, just go out and take a walk. What kind of evidence do we have about alternative treatments as opposed to more aggressive treatments when it comes to actually do medication? DAVID PETERS: Let me say that the most aggressive approach is to do multiple things at the same time. If someone comes in with depression and they are disabled by it, I will not wait for talking therapy to give them immediate relief. If someone is at risk of hurting themselves, so you want to get them to a doctor and get the medications. In the meantime, medications can take up to thirty days to get the effect that you want. It's kind of like trying on shoes. You may like the shoes, but they give you a side effect like rubbing and putting a blister on your heel, to have to change the medication. It could take months to find the right one. In the meantime, what can we do? Talking therapy, cognitive behavioral therapy has proven to be as powerful as medications for some people. For the worst depressions I want to begin with cognitive behavioral therapy, but why wait for talking, when you can make yourself feel better immediately. It's not a cure for depression, but certainly when you give yourself vigorous exercise for 30 to 45 minutes a day, you're instantly raising serotonin levels in the bloodstream and for some people even increasing dopamine levels in the brain, which will make you feel better right now. So for people who are seriously in need I will say okay, I want you to get to the doctor and get on medication. In the meantime, get exercise every day, watch your sleep and wake schedule, be in bed at this time and up at this time no matter how badly you feel. Nutrition is everything. Don't put alcohol in your body when you are depressed, this is not acceptable. Be careful of your sugar take also. We give them a workbook where they can be at home in between visits they can observe the thoughts. That is the key with talk therapy, to assert your thoughts and make it change in how your processing. MAUREEN CAVANAUGH: Doctor Ornish, you must have heard a lot of criticism about antidepressant medications. Of course sometimes medication is essential to treating depression, but it has been said a lot that our society searching for a quick fix, a pill for everything, what is your response from people start talking about that with mental health and the need for medication? STEVEN ORNISH: I think for depression, particularly the more moderate to severe ones, antidepressants are an important part of treatment. But as my colleagues have said, it certainly should not be the only part of psychotherapy. It can be a very important part. Psychiatrist do psychotherapy and those that don't can make for us. By style changes, exercise and diet, the nights sleep, making sure you don't have sleep apnea, storing, fatigue or depleted, those are all important. A pill will not fix everything, but medication can be an important component for the particularly more moderate to severe depressions, like we saw with Robin Williams, who has a very severe depression that was chronic and recurrent, from what I've heard, this is all public information. He had Parkinson's disease, 40% of Parkinson's patients will have depression. For those kinds of depressions, medications can be particularly important. Bipolar or manic-depressive illness is, medications can be a mainstay of treatment. In terms of tolerability, most patients can well-tolerated vacations and they do not have to go on multiple medications and multiple trials. Some patients do, but the majority you prescribe a single agent, they have a good response, the side effects are manageable, and they do quite well. But I agree, that should be augmented with therapy, lifestyle changes, and a very holistic approach. MAUREEN CAVANAUGH: You mentioned sleep apnea, and we mentioned Parkinson's disease as major surgery as possible causes of depression. Do you think that doctors in other specialties give enough information to patients that certain diseases and remedies like surgery can actually cause clinical depression? STEVEN ORNISH: Some do and some don't. Many primary care physicians are on the front lines treating depression, and they are quite sensitive to these issues. There are some, particularly in managed care times, where they do not spend the time it takes to really listen to the patient and spend the time to assess for depression, and then those cases the patient needs to be proactive, tell the doctor I'm not sleeping well, my mood is depressed, I'm feeling sad, I need help. Please do an appropriate evaluation and refer me to the appropriate specialist if you don't have the resources to do that. MAUREEN CAVANAUGH: Graeme, when you bring this message to people also struggling with depression and bipolar illness is, what kind of response do you get with your message of connecting people and doing work that is important to you, to exercise and healthy lifestyle, do you get a positive response or a quizzical response? GRAEME COWAN: It's a very positive response, people just not their heads, because it's what people have found to work. That is one of the things that I wanted to do, to ask directly those who have been through it and come out the other side, winding up all of the variables, and what was most important to you. That is what has to be done to make progress. MAUREEN CAVANAUGH: I'm out of time. Thank you all very much. I want everyone to know, if you know someone who is suffering with depression, or if you are suffering yourself, there's a county crisis hotline, that number is 888-724-7240.