TVO’s The Agenda had a recent episode on depression with four practitioners holding forth with new thoughts about how to treat this illness. Here are some notes.New depression-related research
Dr. Roger McIntyre of the University Health Network told TVO that integration was a hot topic at the recent American Psychiatric Association meetings in Philadelphia.
He noted that treatment of mood illnesses such as depression has long been “siloed” into biological or psychological camps.
“People are coming together and really now believing that the evidence is unequivocal that the pathway to major depression … is indeed an integrated vulnerability of not just genetics or so-called epigenetics,” but possibly poorly-timed exposure to environmental pathogens, he said.
McIntyre said another major issue was resiliency – “What is it about a person or group of people that decreases their vulnerability in the context of enormous stressors and/or enormous vulnerabilities to mental illness?”
Psychiatrists hope this approach can move progress “upstream” so mental health professionals can eventually work on prevention, he said.
Another new theory floating around is that depression is tied to inflammation, McIntyre said.
For more than 60 years, the biological basis of mood disorders has thought to have been an imbalance in brain chemicals such as serotonin, norepinephrine and dopamine.
“It’s very clear there’s not going to be a ‘one size fits all’ model,” he said, with respects as to how people develop the illness.
One new model is that people with a mood disorder are actually in a state of inflammation, McIntyre said.
“As a clinician, I frequently encounter people who have mood disorders and who have what we call an inflammatory co-morbidity” – for example, migraines, cardiovascular disease or diabetes, he said.
For treatment, this could mean targeting these inflammatory systems rather than the traditional brain chemicals, McIntyre said.
“By doing so, perhaps we can not only mitigate symptoms, but get closer to what we call the lesions, what’s actually causing the illness,” he said.
Many academic groups and private-sector players are doing research work in this area, McIntyre said.
Depression not a one-off
Dr. Zindel Segal, head of the mood and anxiety disorders program at CAMH, told TVO that the thinking on depression is that it is no longer considered a one-episode illness.
“In fact, depression is a recurrent, disabling disorder that often can be well-treated, but its dysthymic expressions can remain as a kind a low-level cold continues to exist in the system and impair people.”
This can happen even though the person doesn’t mean the threshold criteria for a diagnosis of depression, he said.
Psychoanalyst Joseph Fernando noted that some people’s depression is related to abuse or trauma of some sorts, while others have been depressed all their lives.
With depression, it’s tough to use the word ‘cured’ in the absolute sense, he said.
But if one means a person has less of a tendency to get depressed or manage onsets better, then one can use ‘cured’ in that context, he said.
McIntyre said men with an extensive family history of depression are obviously at greater risk from genetic and environmental factors.
One interesting area of current research is that men in their late 40s to early 50s whose testosterone levels are in decline could be more susceptible to depression, he said.
Segal put in a good word for cognitive behavioural therapy (CBT) in both reducing symptoms and preventing relapse.
While it can be used without meds, Segal said he’s not doctrinaire about using it alone, noting that some people only partially respond to their antidepressant medications.
Patients who respond best to talk and cognitive therapy are those who can use their executive-functioning parts of their brains – such as attention and memory. They also need a motivation to look at their past experiences – including the painful ones, Segal said.
Those receiving CBT from CAMH are asked to do work at home between sessions, so they also must be prepared for that if they hope to benefit, he said.
Some of that work could include tracking:
- how they speak to themselves
- what they do for themselves
“Not all the magic happens when you’re sitting face-to-face with your therapist. Part of it is a skill that you develop, a way of relating to yourself, that gets built up over time,” Segal said.
Fernando said psychoanalysis is an attempt to go behind the symptoms of depression to gain real insight into the forces shaping one’s life.
Unfortunately, this can be a process that can take years, he admitted, but added the termination phase of psychoanalysis is quite important. Like adolescents, there comes a time when the patient has to ‘leave home,’ Fernando joked.
McIntyre said he rarely sees patients who get better solely by taking medications.
“We now know the combination (of treatment types) is often a calculus of one plus one equals five – a more robust recovery,” he said. “There’s evidence now to show that if you receive CBT, there’s a reduction of inflammation in the body.”
But to benefit from CBT, you have to do the work, and that requires motivation.
Dr. Ariel Dalfen of Mount Sinai Hospital said one problem is that depression is a real illness that affects motivation levels.
A diabetic, as an example, can’t snap their fingers and say they want to get better. They need insulin or medication in most cases, she said, adding it’s the same principle with depression patients.
“I really think the intervention should be tailored to where the person lies on the spectrum,” she said.
Getting proper sleep and exercise are important in recovering from depression. However, lack of motivation is a strong symptom of depression. “It’s a bit of a Catch-22 situation,” she said.
Segal said he tries to get patients aware there is something invisible holding them back. “When people recognize that, the therapeutic path gets ratcheted down,” he said.
People can set unrealistic expectations for themselves. When they don’t reach them, they get frustrated and more depressed, he said.
But by setting more realistic goals, they can slowly improve, he said.
McIntyre said people suffering from depression often suffer from very negative self-critical thinking.
Self-management in the case of depression means doing what you can, but you can’t will yourself out of depression, he said.
TVO’s Steve Paikin did a three-questions interview with TSN’s Michael Landsberg, who has been public about his struggle with depression. Here’s the final exchange:
SP: One last thing: Tell us where you think stigmatizing people with mental health issues is these days. So many won’t get help because of fears they’ll be seen as unreliable at work, or dangerous at home, or in friendships. Where are we on this part of the story?
ML: We’re still living in a world that sees mental illness somehow falling between physical illness and fantasy. Part of the problem is that few will admit they feel that way. It’s like saying “I’m a bigot.” Truth: The majority of Canadians believe that depression is a weakness and not an illness. Did you know Hippocrates wrote 2,500 years ago that “melancholia” was an imbalance? Yet all this time later, we still fall back on lines like “snap out of it,” and “what do you have to be depressed about?” Have we made progress? Yes. Especially in the last few years. But are we near the end? Not a chance. We still live in a world where people will take their own lives before they will share their illness. Sad. Tragic. Avoidable.
Landsberg wrote a column on Sept. 13, 2011 about his friend, former NHL enforcer Wade Belak, who committed suicide. Read it.