With the recent release of the Netflix series, 13 Reasons Why, depression and suicide have been getting a lot of press time. In this episode, we talk about depression, what it is, how it is treated and what’s on the horizon for this far too common disorder.
We also talk a bit about the Netflix series and the problem of suicide. Take a listen and see what you think.
If you think you may be depressed please seek help from a trusted healthcare provider. And if you are contemplating suicide, there is help for you – please contact the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). Someone will answer your call and help you find the resources you need to deal with your depression.
Amy: [00:00:00] Kendall we’ve discussed a lot of medical issues and health policies in our year and a half of podcasting, but we haven’t touched on mental health.
Kendall: [00:00:07] Mental health is a pretty important part of health care overall, and it’s impacted significantly by health policy which is a moving target these days so why haven’t we talked about it?
[00:00:17] Well I always hated psychiatry in med school so I’ve been avoiding it.
[00:00:20] What why.
[00:00:21] Well the diagnostic algorithm always felt very subjective to me. If you have two major symptoms or one major symptom and one minor symptom, you have the diagnosis.
[00:00:31] There is a certain level of subjectivity that’s for sure. But this podcast was your idea. So has something changed your thinking on this topic?
[00:00:39] Well I still wouldn’t want to be tasked with the job of diagnosing psychiatric disorders on a regular basis. And God bless those who take on that very important job. It’s very difficult and often there isn’t a lot of thanks for the effort. But we’re learning so much about biochemical processes involved in mental health issues. I like that we are inching more toward objective data in the field.
[00:01:01] I don’t see the subjectivity going away any time soon. We’re talking about human behavior and feelings. We can define to find a fine but there will always be an element of subjectivity.
[00:01:11] That’s very true, but having a stronger biochemical framework to base treatment on is valuable. And that can help us to find different disorders and even different types of the same disorder.
[00:01:19] Ok then so what are we going to talk about in this episode?
[00:01:23] Hello and welcome to to talk stock. The podcast about health care the science of medicine and everything in between.
[00:01:30] So I wanted to discuss depression because Netflix has that new series out – 13 Reasons Why. The premise is that a young woman in high school has committed suicide and she left behind 13 tapes for 13 individuals who played a role in her decision to end her life.
[00:01:45] Yeah it’s been very controversial. We’ve talked about it a lot in my family too. Many people, particularly in the mental health community, believe it romanticizes suicide.
[00:01:55] Yeah I agree with them. We witness karma coming to call on the people who were truly horrible. And others who were less awful, they see the error of their ways and they want to do better.
[00:02:05] Yeah. For a young person already having suicidal thoughts thinking your death could lead to retribution or outcomes like they depict in this show might be just enough to encourage them.
[00:02:15] Yeah. So is there evidence that this happens from watching a TV show?
[00:02:20] Well we know that the phenomenon of copycat suicide or suicide contagion is real. But it typically occurs after a celebrity suicide like Marilyn Monroe’s death. There was a 12 percent increase in suicides.
[00:02:34] But do copycat suicides happen based on fictional characters?
[00:02:38] Yeah. The most well-known One is that book in the 1800s called the Sorrows of Young Werther. And I’ll say it right. I don’t know w e r t h e r sounds like a German dude. Yes they had a whole bunch of sort of copycat suicides because of that novel. But it’s worth noting that most countries have formal or informal journalistic standards about reporting on suicide because of the concern over triggering copycats. So this show 13 Reasons Why has a lot of people concerned.
[00:03:17] I can see why. So is there anything good in the show?
[00:03:22] Yes. It touches on a lot of very important social issues – bullying, sexual assault, stuff like that. There are real issues that may contribute not only to depression and suicide but they can create a hostile environment for lots of kids on a daily basis. And the series calls those issues out. That’s probably a good thing. The other thing also is that it’s causing lots of conversations. I’m sure that wouldn’t have because of it.
[00:03:45] Yeah. OK. But we’re not talking about those social ills so much as we are talking about depression.
[00:03:51] Yes so if we’re going to talk about depression let’s get a handle on the scope of the problem.
[00:03:56] OK. So it’s everywhere. Between 2009 and 2012, one out of 20 people over age 12 reported current depression meaning they were diagnosable as depressed during the previous two weeks.
[00:04:09] So at any given time five percent of the population is suffering from depression. So if you narrow it down to the forty to fifty nine year old age group that number jumps to 10 percent. The World Health Organization says it’s the third most important cause of disease burden worldwide.
[00:04:25] So that’s a huge public health concern and depression costs about $10 billion in the U.S. each year. Those costs come from things like lost productivity direct medical costs and the costs of suicide.
[00:04:37] So this disease affects us all. And pretty directly.
[00:04:40] It really does. So how do we diagnose depression?
[00:04:45] So the diagnostic criteria for major depressive disorder which is the formal name for what we think of when we think about just straight up depression these criteria are found in the Diagnostic and Statistical Manual version 5. We abbreviate it DSM 5. This manual includes all defined psychiatric disorders and their diagnostic criteria.
[00:05:06] Right since you can’t just get a lab test to diagnose depression like you can with thyroid disease. The criteria in this manual serves as a uniform diagnostic algorithm that acts as a standard for anyone making the diagnosis. We’re all on the same page.
[00:05:22] So if I presented with the same symptoms to a half a dozen doctors they should all come to the same final diagnosis based on DSM 5 criteria.
[00:05:29] Theoretically but let’s talk about the criteria we can see how it isn’t always quite so black and white.
[00:05:34] Yes. So to be given the formal diagnosis of major depressive disorder you must have five of the following symptoms continuously for two weeks.
[00:05:42] Can you read these really really fast.
[00:05:44] Yes. Feelings of sadness, hopelessness, depressed mood. Loss of interest or pleasure in activities that used to be enjoyable. Change in weight or appetite – either increase or decrease. Change in activity – psychomotor agitation or psychomotor retardation. Insomnia or sleeping too much. Feeling tired or not having any energy. Feelings of guilt or worthlessness. Difficulties concentrating and paying attention. Thoughts of death or suicide. So you got to have five of those for two weeks in a row.
[00:06:13] OK. Every day? Every day or nearly every day and cause significant distress or problems with the way you function.
[00:06:24] Yes. Also they can’t be better explained by another diagnosis psychiatric or otherwise.
[00:06:28] Like a drug.
[00:06:30] Or a brain tumor.
[00:06:31] Or there are other psychiatric disorders that have depression as a component like bipolar disorder for example. But they also have manic episodes so that would not fall under major depressive disorder.
[00:06:42] So you can see where some of this could get quite subjective for example. Most moms of young children claim a lot of these symptoms and they don’t consider themselves depressed.
[00:06:52] But there sure are tired and they don’t have any energy. And some moms always feel guilty. I mean so you know there’s a lot there. So that’s why it’s so important to have someone who diagnose and treat depression on a regular basis make this diagnosis. They have enough experience to recognize symptoms are more circumstantial and not necessarily a red flag.
[00:07:12] OK. So in addition to the diagnostic criteria there are some behaviors and conditions that are associated with depression.
[00:07:18] Like smoking which surprises me. Alcohol consumption which doesn’t surprise me. Obesity and physical inactivity. Sleep disturbances, epilepsy or seizure disorders, and HIV AIDS.
[00:07:32] Yes. So you can see that this can often be a chicken and egg thing. Yeah hard to know what came first. But the association is there.
[00:07:40] So let’s talk about what causes depression.
[00:07:42] OK. Well first we have neurotransmitter issues.
[00:07:46] OK. Neurotransmitters those are sort of like messengers in the brain.
[00:07:50] Right. Yeah.
[00:07:50] One of them serotonin is a big player in the whole of the whole area. Depression yes when serotonin is released it binds to receptors in the brain. And this is supposed to make you feel good. But the thinking is that there’s not enough serotonin available in people who are depressed. And so they don’t feel good. Yeah.
[00:08:11] So this is what many of the modern antidepressants – selective serotonin reuptake inhibitors – target.
[00:08:16] Yes so these drugs – SSRI’s for short please – they are common and we all know that Prozac, Zoloft, Paxil – those are their brand names. And these re-uptake inhibitors prevent the reabsorption of serotonin so that it stays on the receptor longer. But we aren’t exactly sure if that’s how they work or if they do work.
[00:08:43] Or if they work, actually the evidence for the effectiveness of these drugs for mild to moderate depression is mediocre. Multiple meta-analyses and reviews have been conducted over the years and the results are just not all that exciting. Well link some of those in the show.
[00:08:57] Yeah SSRIs are recommended for patients who have persistent depressive symptoms after other interventions like cognitive therapy but they are definitely not a silver bullet. And like any medication they come with some real adverse effects.
[00:09:13] Yes. So this neurotransmitter theory has been the working theory for a long time. Do we have other ideas about what might cause depression.
[00:09:19] Yeah hormones There are culprits in some cases and this can be the case particularly in postpartum depression of course, and during menopause, and when there are thyroid issues.
[00:09:31] Mm hmm. Yeah. And the propensity for depression is more common in those with family history. So the search for a genetic component is also under way.
[00:09:40] Yet the area I think is very exciting is actually differences in the brain.
[00:09:45] For example a study in Nature Medicine in December 2016 used functional MRI to look at the brains of 1000 people. About 40 percent of them were depressed. They were able to identify four different functional depression types.
[00:10:01] Yes so this seems like it could be very game changing the way we think of depression now is as a single disorder. But that doesn’t really make a lot of sense. I mean think about insomnia or sleeping too much? Gaining weight or losing weight? Being more active or less active?
[00:10:19] I see what you mean is someone who is losing weight, struggling with insomnia, and agitated dealing with the same disease as someone who’s gaining weight, sleeping all the time, and barely getting off the couch? Sure doesn’t seem like it. But if both of those people were sad and feeling worthless they would both have the diagnosis of depression or major depressive disorder.
[00:10:36] So this direction of research could revolutionize the way we think about depression. Optimistically speaking.
[00:10:42] So the National Institutes of Mental Health seem to think so too. Because in 2008 they launched the research domain criteria. Researchers are encouraged to look for mechanisms for mental illness and not just lump people under one umbrella based on broad symptom sets. And areas of research are exploding as a result of this. They look at a variety of domain criteria and they include negative domains like fear, loss, and threat; positive like reward and habits; cognitive like attention, perception, and memory; social like communication and self perception; and arousal like circadian rhythms and sleep and wakefulness. So researchers can then correlate biomarkers such as environmental toxins hormones or free radicals with these different domains.
[00:11:26] Well this could explain why SSRIs aren’t effective across the board.
[00:11:30] Right. There’s maybe one subset of depression and it would work for.
[00:11:35] And maybe they can sort of pinpoint the patient where they’ll work best.
[00:11:39] And it can help develop new treatments for depression that are targeted based on the specific neurobiology of patients rather than the more blanket approach used now.
[00:11:47] Yes very exciting but probably not all that helpful for the 5 percent of people who have depression now.
[00:11:52] You’re right of course. So let’s talk about treatments that are available today for depression.
[00:11:56] OK. First as with anything medical it’s preferable to stay as non invasive as possible. So we start with therapy by the way and we’re reminded of my psychiatric rotation in med school at the V.A. I was on the ECT.
[00:12:10] I remember that.
[00:12:11] It was not exactly noninvasive.
[00:12:14] No. OK. So cognitive behavioral therapy to be exact is is a very common and useful starting point in this type of therapy. Patients are trained to recognize the negative thought patterns that often become automatic with depression. They’re taught to correct those thoughts.
[00:12:31] I like to think of cognitive behavioral therapy as aligning your emotional, physical,and practical lives so that they are congruent.
[00:12:42] that’s a good good way to think about it I think. I like that. So it’s not about learning to lie to yourself or fake it til you make it.
[00:12:50] Right. But it’s taking those persistent negative thoughts that are exaggerated and untrue like I’m failing my children in every way and turning them into something closer to reality. It’s finding the places that you’re doing well. “My children know they can come to me for love and support at any time.” And putting the shortcomings in perspective. “I should set aside time each day to read to my child” that kind of thing.
[00:13:14] Yes. So nothing changes except the self-perception and it’s often this self-perception that feeds depression.
[00:13:23] Yes. This type of therapy has shown to be as effective or even more effective than pharmaceuticals for treating mild to moderate depression. And it works very well in tandem with pharmaceuticals.
[00:13:33] Yeah. Now these pharmaceuticals include the SSRI is that we spoke about earlier as well as several other classes of drugs. Finding the right drug will depend on other health problems you may have and how you react to the drugs you try because they come with a range of side effects.
[00:13:48] Yeah. And as we mentioned before. And it’s important to work closely with a physician who you can trust to find what anti-depressant will work for you. If you don’t have a good relationship it’ll be really difficult to share your concerns about the symptoms and side effects of the drug
[00:14:05] Yes. And finally there are treatments that affect the electrical activity in the brain. The first has some bad associations because it has been abused in the past.
[00:14:13] That’s what I”m talking about – the ECT.
[00:14:15] Electroconvulsive therapy delivers an electrical current to the brain.
[00:14:19] It’s used for people who have very severe depression. And in all honesty these people in the V.A. were they they had very severe depression. Most of them had attempted suicide. They had psychotic features. And they had tried multiple modalities all of which had failed. It is done under anesthesia. So there’s not the noninvasive part right out the window. And can result in temporary memory loss headaches and all the other complications of anesthesia that you would see. But usually these are manageable and short lived.
[00:14:54] and for the people who need it is it can literally be lifesaving. It can provide immediate relief to severe depressive symptoms possibly from its impact on neurotransmitter activity in the brain.
[00:15:04] Yes. Transcranial magnetic stimulation or TMS is similar but is similar to ECT, but magnetic pulses are sent through the brain. This is performed awake and is painless and is performed daily for several weeks and often provides relief for those who medications haven’t worked. And it’s a newer treatment and growing in popularity you can see why. You would rather have that than ECT.
[00:15:30] Definitely. So finally we need to circle back to 13 Reasons Why: suicide. Suicide of course is the worst possible outcome of depression. These thoughts should not be taken lightly. If you are having them yourself or if someone you know is, there is help out there for you but you must seek that help for it to be of benefit.
[00:15:47] Yeah and if you struggle with depression see your doctor. They’re trained to help. We are actually you know we hated psychiatry or Amy did anyway. And if you feel as if you want to hurt yourself please call the National Suicide Prevention Lifeline at 1 800 273 8255. 1 800 273 TALK. There are people who want to help you and things can get better.
[00:16:11] OK. That’s our show for today. We hope you learned some interesting things about depression and we hope you will seek help if you’re struggling with depression. There are some great options out there to help you.
[00:16:20] So let’s close out this show with a shout out to rap artist Logic. He dropped an album last month called “Everybody” featuring the song 1 800 273 8255. It tells the story of someone who is contemplating suicide and that how they got help to the National Suicide Prevention Line. Yeah well way to go logic.
[00:16:39] Yeah let’s help Logic get his song to the top of the charts. That’s awesome.
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