Basic depression treatment

In this episode of PodMD, experienced Psychiatrist Dr Jason Pace will be discussing the topic of basic depression treatment, including how a patient typically presents with depression, the treatment options, new developments in treatment, when to refer and more.


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  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Jason Pace

    Dr Jason Pace is an experienced Psychiatrist who established and practices at Sydney TMS, an innovative clinic providing treatment for Treatment resistant depression where other treatments don’t seen to be working. TMS is short of Transcranial Magnetic Stimulation.

    After graduated from the University of UNSW in 1996, Dr Pace founded the Hills Clinic private hospital in Kellyville in 2010 which included one of the first private youth mental health inpatient programs in NSW. In 2014 Dr Pace launched Sydney TMS, after traveling to America and visiting several TMS clinics in the US. At that time Transcranial Magnetic Stimulation, TMS for short, was virtually not heard of in Australia. Jason now operates four TMS clinic locations across Sydney and practices at all four, offering extensive experience in TMS treatment.

    Today, we’ll be discussing the topic of basic depression treatment.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Jason, thanks for talking with us on PodMD today.

    Jason: Thanks for having me.

    Question 1
    The topic of today’s discussion is basic depression treatment. Jason, can you give us first give us a brief overview about depression?

    Jason: Sure. Well, depression is. It’s a brain disorder. It’s characterised by sort of several different things. I guess most people would be aware that depression. Often presents with being sad or being low in mood, but I guess it’s a bit more complex than that. You know, depression often can be initiated by a particular stress. It could be grief, it could be a work issue, relationship issue, or a trauma, but for some people, depression is more of a condition that sort of slips into their being for no particular reason. And this could be individuals who might have a genetic component of their illness. And there could be a family history of depression and they might be more prone to suffering depression for no obvious reason.

    Other ways of seeing depression is, it can be a single episode, or it could be a recurring episode. Perhaps some people have repeated episodes of depression. And I guess other types of depression that you might consider would be either a unipolar or bipolar. So, with unipolar depression, people would have single repeating episodes of depression with a bipolar depression or bipolar affective disorder. People will have this sort of pendulum effect where they might suffer depression, and that swings to high mood or mania. And they sort of oscillate between the two often. So depression can be as sort of a standalone condition or it can be a part of other a greater condition or a larger condition, I guess

    Question 2
    How would a patient with Depression typically present?

    Jason: So people will often present quite late in the piece. So I guess the first thing to say is that people that often have been struggling with symptoms of depression for quite some time before they seek help for it, they may come in specifically asking for help with depression. They might say I’m feeling sad. You know, I’m stressed. But a lot of the time they can present with other symptoms as well. So and a lot of symptoms with depression are quite nonspecific, so they can mimic other conditions as well, and typically someone might present with symptoms that might mimic more of a physical illness. So one way of looking at depression is to think about the way it makes us feel, the way it makes us think, and the way it makes us behave. And these are the three main ways they can present.

    So they can feel depressed. They can feel tired and lethargic, and depression has a very strong component of energy. So along with depression, depressed mood, you can often feel very, very lethargic, lacking motivation. The way we think can be affected, so people can feel quite hopeless, quite low self-esteem, quite desperate. And if it gets really bad, they start to think obviously a lot about suicide and about their worth of their life and whether it’s worth them being around. And the way that they behave can be affected so they can be withdrawn, become more irritable, they can start to feel sort of quite isolated from other people.

    And it can be that actually the person might come along with a partner because the partner is finding that they’re really difficult to manage at home and their relationship is deteriorating. So it can be the person themselves presenting or it can be someone else is bringing them along for help as well. Obviously if things get really bad at depression, their daily activity starts to being affected. So, you know, they don’t have a shower every day. They can’t get to work. They’re missing work and study. They’re starting to sort of really struggle to do anything in particular during the day. And if it gets very bad, you know, sometimes people could be basically stuck in bed all day or just not live. In the House very much.

    Question 3
    What are the risks/efficacy of the condition?

    Jason: Well, the risk of depression really come down to the functioning level that the person might have, depending on how severely they’re depressed. So I guess the things we are concerned about ourselves the most with is obviously suicide and risk of self harm. But before we get to that, there’s a lot more things that go on that can be put at risk as well. So cognition is affected, so people really start to really struggle to study and get the school or get the university their focus and attention at work can be really affected, so they can they put, you know, risk of them losing their work or having performance managing because of their issues around the work performance. Their connection with other people can really be affected, so the risk there is that you know they damage relationships, they can have arguments, they can be distance and both intimate relationships and more and more sort of friendly relationships can be affected by that. People can start to wonder what’s going on and they can really sort of cause a gap in the relationship for people.

    Sometimes these are, you know, repairable. Sometimes these can be really bad and they can really damage relationships more long term. Other risks are that people start to do reckless things so they can start to drink more alcohol, use more drugs, drive more recklessly, gamble more. Just do things that are sort of really sort of almost a self-harming type of behaviour. But in a way that starts to really put them at risk. And some people do really unusual things like they get into. You know to do reckless things that they would never do otherwise, they might get to fights or start stealing things at the shops and it’s so it can be really, really unusual and it can lead to some legal activities sometimes as well if they get if things get really severe.

    Question 4
    What are the treatment options?

    Jason: So the treatment options really again you would you would approach these depending on how severe someone’s presentation is. But I guess the first line of treatment for depression would be talking treatment. So a GP may spend a bit of time just trying to understand what the person is going through, if they can identify a particular stress that’s contributing to the depression. It may be worthwhile that they have some talking therapy with a counsellor or a psychologist, and that could be all they need. Sometimes that’s enough to get them through a period of grief or a period of stress. Or a period of sort of arguments with work or relationships.

    If that doesn’t help, or if they’re more pervasive symptoms. Obviously, we look at medication as being the next line of treatment and most GP’s would be aware of things like SSRI’s or selective serotonin reuptake inhibitors, things like. Prozac and Zoloft and things like that, which are typically used by GPS and psychiatrists as a first line treatment, and these medications could be very effective if those types of medications don’t work, we have other sort of medications that might be more effective. Things like SNRIs or tricyclic medications.

    Then moving down the the moving down the list. I guess we have things like mood stabiliser that can be sometimes added by a specialist as well. Some GPs are comfortable using those medications, some will refer on to a specialist psychiatrist to prescribe those medications. And then finally, we have some non-medication treatments. So we have obviously things like being put in, putting people in hospital if there’s a risk of self harm, or if there’s a danger to the person and outside of hospital we would look at things like transcranial magnetic stimulation or TMS, which is now readily available. That’s an outpatient sort of treatment for people who don’t respond to medications. And then finally, I guess the very last or thing on the list would be. Electric convulsive therapy, which is something that you do as a hospital stay and it’s probably the, I guess the final effort to try and get someone well if they’ve failed to respond to other things completely.

    Question 5
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Jason: Sure. I guess, look, I think most people are aware that that they’re there’s medication we do have available to us at the moment. While they’re good, they do come with their own problems as well. There’s quite a lot of side effects that people experience with medications. So in the last few years, we’ve seen pharmaceutical companies trying to develop newer drugs, different agents. Maybe different classes of drugs that might be, you know, more tolerable to people because we know that 50% of patients don’t take their medications properly because of side effects with medication, so. I guess in the last probably 10 years or so, we’ve seen things like agomelatine, which is a a medication that doesn’t affect serotonin. It works on the melatonin pathways to help depression and a drug called Reboxetine, which is another medication which doesn’t affect serotonin, which we explore in the adrenaline pathways to try and help depression. Without those typical sort of SSRI type side effects, things like sort of sexual dysfunction, which people often complain.

    The next developments, I guess beyond medications would be things like transcranial magnetic stimulation and TMS, which is now pretty readily available in Australia, and this is for people who have tried quite a few different medications. You know, Medicare suggests that if you’ve tried 2 anti depressants, you’re not getting the result. One you could look at TMS as an option, and now it’s a Medicare funded sort of treatment and other things I guess that might be on the horizon. And and I just had to be talked about now I think we maybe they’ll be clinically available now, but will be probably in the next few years would be things you know there are other types of medication which are sort of very different to what we’ve been using up to now. So things like ketamine, which is typically seen as an anaesthetic or a pain medication and there’s some trials with ketamine now being used for depression.

    And quality of hallucinogen medications sort of psilocybin and the like, who which were also now starting to be researched again and are quite likely going to be available for use for depression in the next few years. At the moment these medications are being trialled and I think initially they might come on. On board, maybe in the next two or three years and they might be available and at some point Medicare may fund those treatments, they’ll become more readily available. So there’s a lot on the horizon. I think there’s lots of things to consider, but at the moment, I guess the things available to most GPS at the moment would be the medications different class of medications and maybe TMS as a. As a second line treatment for that.

    Question 6
    Are there any warning signs a GP or their patient can look out for?

    Jason: Sure. Well, I think, I guess when you’re treating depression apart from the depressive symptoms, we’ve talked about, the other thing is to consider as a GP is how long you are waiting for a response from the treatment and how quickly you should be reviewing patients. So typically you know a medication like an SSRI is going to take about four or six weeks to have its effect. So I guess it’s important once you start some on medications, you bring them back in that time to see a how they’re tolerating the medication and B how they’re responding. If they’re having any sort of symptom improvements.

    And one thing I would recommend clinicians do is use some form of. Screening tool. Things like the Patient Health Questionnaire, which is just a one page nine question really simple thing to use and it’s a really simple language and it just helps you track how people are going, particularly if you’re in a sort of a busy sort of practice and you don’t have a lot of time to go through all this. You can this this sheet to someone to take home and bring back with them so they can sort of not be taking time up in the consolation to users in the rooms, but that really helps you work out whether you’re getting any movement happening with this patient symptoms. And I think, you know, monitoring symptoms is really important for to keep and eye on.

    It’s important to also broach the question about suicidality and safety, because it’s a question often people feel really uncomfortable to ask about. But if you don’t sort of at least open the gate to that question, it may be something the patient feels you’re not wanting to know about. So I think asking about whether they’ve had thoughts of, you know, death or death. Or thoughts of harming themselves is a really important question to address. Finally, I’d say the other things that are important is to keep an eye on the time and how long it’s taking you to get someone. Well, the key is to try and work on being a pretty aggressive at treating the depression in the first six months of someone presenting. It’s really important that that’s a key window. If you are depressed for a long, long period of time. The chances of having A difficulty recovering from that episode of depression and B lots of relapsing depressive illness in the future is really, really increased, so we already know that people have spent quite a few weeks and months suffering before they come to see us. So from the day they come in a training point that we’re sort of working on a timeline of really no more than six months to try and get them well.

    And considering it, you know, a medication trial takes a month, you know, you don’t. You don’t want to be sort of sending someone away for three months and say, come back in three months before they review your. It’s important to them more regularly than that. And finally, the thing to keep an eye on is just is, you know, how many medication trials you’ve had. If you’ve tried two end depressants and you’re looking at doing your third. Or 4th evidence which is yes, it’s probably unlikely they’re going to respond to just doing more and more medication trials without the changing things, so you can’t really expect a different result if you keep doing the same thing.

    Question 7
    What is the likelihood of recurrence of the condition?

    Jason: So unfortunately, depression is a relapsing condition for a lot of people. It’s far, far more likely than people would sort of think. If someone has a full response and reaches remission with their treatment, they’re in a much better position to not have any further episodes of depression. But if someone has, you know, an improvement in their in their depression, but they may still have residual symptoms, the chance of them relapsing is quite high. And again, this is why it’s important to sort of try and quantify this with using some questionnaires that you might sort of feel comfortable using and understanding. Depression we believe there’s a sort of a, you know, what we call a kindling effect. So the longer you spend being depressed, the more likely your brain is to sort of set that as the bit a bit of a default mode for being.

    So it’s important that you spend far more time not being depressed and being depressed. And the longer you are being depressed for the much more likely chances of you going to be relapsing back into that into that place. So if you get someone, well, it’s important to keep them on medication for a long period of time as well to keep them well for a long period of time. So if they’ve been depressed for a year or six months. It’s important to keep them on medication for at least that long, either recovered to keep them sort of in a good place and get their brains sort of defaulting back to, you know, being in a healthier place. If you stop medications too early off when you relapse quite quickly afterwards as well. And I guess the other thing to consider is that if people have had two or more episodes of depression in their life, the chance of having them having recurrent depression is probably 50%. So there’s more, you know, they’re pretty high. So once you’ve accumulated two or three episodes of depression in your life, the chance of having further depression in your life is quite common.

    Question 8
    When should a GP refer?

    Jason: So I guess very early on, if you’ve got someone with mild depression, you know it’s probably not a bad idea to think about referring on quite quickly to a psychologist or to a counsellor, particularly if you identify someone having a stress that can be pretty easily identified having some talking therapy early on is going to make recovery a lot easier. And you may do that before you do anything else, but you might refer them to a psychologist before you even start any medication sometimes. And that’s quite reasonable to do. I think if if you. You know, consider the range of depression that we have. You know, there’s a very good chance that 50% of depression that that it’s in the community can be very adequately treated with a GP, using some medication and with the assistance of a psychologist, I think that will get you out of trouble. At least 50% of the time.

    But we do know that there’s at least 30 or 40% of patients who have what we call treatment resistant depression. So they really struggled to reach a full remission with the conventional sort of treatment. Certainly a first line treatment. And so I think those patients, if you identify them and you’d be aware of them, I think it’s important to consider referring them to a special psychiatrist pretty early on in the piece as well. So if you’re sort of two medications trials down and seeing a psychologist and you’re sort two or three months down the track with someone and you’re really struggling to see. Significant improvement.

    Or there may be a partial improvement, but you’ve sort of reached a bit of a plateau and it doesn’t look like you’re get to a remission. Then I think those guys need to be referred on pretty quickly and considering, you know, at the moment in most states of Australia, it’s very hard to get into, see a psychiatrist. You know, if you’re thinking about referring someone today, they may not get in to see someone for two or three months time as well. So. In that you’re a factor that, when the referral is made, it may still be quite a few months before you actually get to see someone as well, so I would be thinking about it pretty early on. I think certainly within sort of two or three months of seeing a patient, if you’re not happy, they’re doing really well. And I think certainly a psychologist very, very early on in the piece.

    Question 9
    What role does the GP play in the treatment of the condition?

    Jason: Our GP role is pretty key because the GP is going to. Beat, as I said, at least half of the patients that they see with depression are pretty much on their own or whatever with the assistance of a psychologist. But even if they are involved with the psychiatrist, the capacity for a psychiatrist to review a patient is going to be maybe one every once every few months. You know, they’re going to make some recommendations, and they’re gonna refer the patient back to the GP for managing that that recommendation. So I think the GP’s role is specific is a key role in managing things and observing things more regularly as well.

    I think people would with moderate to severe depression need to be kept an eye on pretty closely to make sure things don’t deteriorate and to also just keep people motivated to keep going with their treatment. You know to keep the compliance up, make sure they’re doing it. Even non medication things for depression. Make sure they’re trying to get to the exercise and make sure they’re eating reasonably well. Make sure they’re sleeps OK and if you don’t do this quite regularly with patients, they sort of really do get a bit sort of tired and fatigued with their illness and they don’t do this so. Having a regular catch up with the GP every couple of weeks when you’ve got that sort of severe illness is really important. If you just leave it to a psychiatrist to review the GP every as a patient, every sort of three months or so, there’s a lot of things that get missed along the way and. People aren’t going to do as well.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on basic depression treatment

    Jason: Sure. Well, I think we’ve got a couple of key things for me is to think about depression as a multi factorial condition. It’s not about just being sad or or lower mood. It does definitely affect the way it affects your energy levels. It affects the way we think our capacity to think and our cognition and it certainly affects things like our relationships and. And socialising so it’s. It’s not just about being low mood, it affects several aspects of your your being. The second thing I would say is as treating a depression, it’s important to have a bit of a plan of how you’re gonna monitor people’s progress, maybe using some scales.

    It’s important to have an idea what a partial response is and what a remission is and have some timelines in your in your I guess diary about how you do this and what you’re sort of looking for so you know. At the four at the four or six week mark, what am I expecting? You know if if nothing happens at that point, what do I do next? Have a bit of a plan and how you approach this in a pretty? Methodological way. I think that’s going to give you a really good outcome. It’s important to understand that that you know, depression doesn’t look the same with everyone and there isn’t a patient that looks like they might suffer depression. It can affect anyone, really.

    And I think just consider the number of patients you’re going to be seeing who are going to be treatment resistant and don’t hold on to those patients for too long. It’s important that you consider whether someone needs to be seeing a specialist. Then someone needs to be having TMS treatment or being hospitalised. You know that needs to be sort of pretty forefront of your mind and thinking in in these patients.

    Thanks for your time and the insights you’ve provided.

    Jason: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.