Effective MDD Therapies

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, the Chief Medical Officer at WebMD. And we're continuing our discussion about major depressive disorder. It's a mental health disorder characterized by a persistently depressed mood or loss of interest in activities that causes significant impairment in daily life. It's a serious but treatable illness with several therapeutic options, including medication, psychotherapy, and talk therapy.

Now we talked previously about the importance of diagnosis. Now I want to spend some time talking about why, how, and when we treat. So joining me for that discussion is Dr. Joseph Shrand. He's an Instructor of Psychiatry at Harvard Medical School, as well as an adjunct faculty member on the medical staff of Cambridge Health Alliance.

And Dr. Ludmila De Faria. She's Associate Professor at the University of Florida College of Medicine and the Chair of the APA Committee on Women's Mental Health. Doctors, thanks for joining me again. It's nice to see you again.

Good to see you.

Nice being here.

Well, let's start off. We talked about why diagnosis is so important and how we do it. Now not everything needs to be treated. So what are the indications for treatment of major depressive disorder, specifically the role of medication?

Well, when you are diagnosed with major depressive disorder, whether it's mild, moderate, or severe, then it is an indication that the process of being sad is advanced and it is impacting functioning. At that point, I think that whoever is struggling with the feelings of depression needs to discuss medication with their doctors.

Lucky for us, and I tell that to all my patients, medications can vary in their side effects. And so if you don't like a particular medication, there are many others that you can treat. And they may reverse the process within four weeks, which is pretty good to go from not functioning to being on the way to recovery within about a month to six weeks.

And that's usually the minimal process, right? In terms of even seeing an impact. You have to try medication for many weeks and then reevaluate. Is that correct?

That is correct.

And do most people need to be on medication? What's been your experience?

That's a fascinating, fascinating question. I think many people certainly do. It really has to do with your quality of life. If you feel that you're not functioning at the level that you used to, medication may be important.

But what's fascinating is how many people are resistant to medication because they think it confirms their worst nightmare, that they're broken and that they have less value, which is what's going to make them even more depressed. I want people to understand that there's nothing broken.

When we add a medicine, all we're doing is making a small change in your biological domain of your brain. You change the environment to those brain cells, you're going to change their response. Nothing's broken. That small change can have a big effect.

And you may not respond to the first medicine. That's one of the real difficulties that we have in psychiatry, is we don't have those instruments that can say, here's where the break is. Here's where the problem is. So you work with your psychiatrist or your prescriber, whoever it is. The most important thing is to trust them.

Well, I want to ask you about the prescriber, because some people will be thinking, well, I need to go see a psychiatrist if I need medication, and there's a lot of mental health issues right now in terms of the pandemic. So does it matter who you see, whether you see your primary care physician or a psychiatrist?

I think that initially to get the diagnosis, they can see whoever can help them. For a mild case, I have many primary care physicians that are colleagues that are comfortable initiating medication, and they only refer the patient to a psychiatrist if the patient fails two or more medications. And then they consider there might be other things at play, and they want a psychiatrist to look at that. I mean, for me, it's about access.

That's a great point. They should see who can help them and not be as worried about whether they're a psychiatrist or a family medicine physician or internal medicine.

Or a nurse practitioner.

Or nurse practitioner. Exactly.

I feel like, do I want everybody to suffer with a major depressive episode for three months until they can see me? I hope not. I often tell people, just go ahead and try, and then I'm happy to take in what we call the higher acuity cases, right? The more severe cases. Let them come to me, because I have a little bit more expertise in seeing, why is the medication not quite working?

So I wanted to take a few minutes to explain to our audience how medication has changed, even in just the last few years.

LUDMILA DE FARIA: With the advent of genome mapping, what a lot of pharma industries were able to do is go back to the bench and design medications that fit better certain genomic profiles.

Tell me about that. That's very interesting.

Well, you know, we hope that one day when I go to the doctor to get treated for depression, or when you go to the doctor to get treated for depression, Dr. Whyte, we are going to get completely different approaches because they're going to look at your genetic profile and mine, and they're going to do an individualized treatment plan, right?

And we're not quite there yet for psychiatry, but we're a little bit there. A lot of the data gathered by all of those genomic tests that people do at home for ancestry and just self-knowledge, all of that data gets pooled, and pharma uses that to then tweak medications and make sure that a higher number or a higher percentage of the population will respond to the medications with less side effects. And that's how some of the medications have improved over the last few years.

I want to ask you about the role of nonpharmacologic options. Are they primarily adjunctive? Can they be the primary source of treatment?

I think you can certainly have both. And part of it depends in some ways on the degree of the depression. The medications are going to be very important, but that's not all you need.

There's something called Cognitive Behavioral Therapy, CBT, which is where what you think affects what you feel. When you recognize that you're depressed, there are all sorts of emotions and things that happen in your body. You recognize it. You can then potentially rate that depression, let's say between 0 and 10.

And then you can remember. And you have to remember that it always gets less. And then you can reflect, what was I thinking that made me depressed? Did I think that those people were looking at me in a way that makes me feel less valuable? Am I worried that I'm not going to be able to complete my task and my boss will fire me? These anxieties and depression can go together, and so we can use a thinking tool to help us with it.

How does treatment for persistent depression differ than for major depressive disorder?

That's where psychotherapy is really valuable. And so you really need to go through psychotherapy to identify these twisted ways of thinking and undo certain patterns of behavior. So especially for persistent depressive disorder, I would think that psychotherapy can be considered a primary form of therapy. And then medication, if we need to tweak the functioning a little bit while the therapy is going on.

I want to go back to this point where some patients feel they don't want to start on a medication because once they do, to your point, Joe, it confirms the diagnosis in their mind. And there's still some stigma associated with mental health disorders.

John, your point is so important. What about the word disorder? Let's talk about stigma for a moment. Just think about the word disorder. What do we mean? What are we telling a patient when we use that word? That there's one group that's OK and one group that isn't, and then we're astonished we have stigma. The word disorder in and of itself may be perpetuating the greatest fear of our patient, that there's something broken.

And we should work on that labeling. We know words have meaning, so we have to think that through.

Yes, and I really hope people do. It's a condition. You're not broken. You're not broken. Look, there are 250 million people in the world with depression. Come on. That's a huge number. And with COVID, what's happened with COVID? More people have been isolated away from their social group. That's a setup for depression.

Well, doctors, I want to thank you for this robust discussion about we need to diagnose it, and then we need to treat it. And we need to remove that stigma that still exists sometimes of treatment, because as you both point out, there are many options available today and many on the horizon. So thank you for taking the time today.

Again, my gratitude to you.

Thank you very much for having me here.

If you have any questions, drop us a line. You can email me at [email protected]. Thanks for watching.

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