Q: What is depression?

A: Depression is a change in your mood from a normal mood to a persistently sad mood. Psychiatrists use something called the DSM, which stands for the Diagnostic Statistic Manual for Psychiatric Disorders, for a guideline. If you were to look up depression in the DSM, it would say a persistently sad mood every day for more than 3 weeks.

Q:What if you have been sad for that time period but you’re still not sure it’s really a clinical depression. How do you know the difference?

A: I’ll give you a story as an example as to how to tell the difference…Let’s say that you have a cold, that you have a runny nose and a sore throat, and that you feel pretty lousy, right?? But you know in a few days, it will go away—but if this cold turns into pneumonia, it probably won’t go away unless you use antibiotics. It’s a little bit like that with sadness.

We all get sad, things go wrong in our lives, we get disappointed at times—and the sadness is usually temporary, but if the sadness turns into a clinical depression than you feel it not only emotionally but physically. My advice for someone who suspects they are depressed, is to seek psychological treatment because sometimes if you can get a good therapist who can help you with some grief work or can help the person get a boost in their morale, you may be able to head off the clinical depression. If somebody feels supported emotionally, if they don’t feel alone, they can feel a whole lot better. It’s when you feel alone and lost that depression is really worse.

Q: And what are the symptoms of clinical depression?

A: You will have this sad mood every day, like a heavy weight on your shoulders. Most patients usually have a desire to sleep a lot, just because it’s safe in bed, away from the real world. Sometimes they have difficulty falling asleep or sometimes they wake up in the middle of the night. Patients may lose their energy, their motivation and they may become less hopeful about life. These hopeless feelings are very difficult. They may have changes in appetite, which can go either way…some patient overeat when they get down —and other patients stop eating. Many people lose their desire for sex. If it’s someone who is athletic, maybe she won’t want to go running anymore. I had a surgeon patient who came in a year or two ago and she said, “Dr. Elliott, I have to be depressed because I have skied every year of my life and I now have missed two seasons”. It’s that change in behavior where once something was a great passion and now it’s now it’s no longer of interest.

If these symptoms become more severe, the person may start to feel suicidal. Suicidal thoughts can occur when someone has been in emotional pain for too long and they see suicide as a way out.

Q: Can you give some examples of things that would trigger depression, both emotionally and physically?

A: Sure, obviously as a psychiatrist whenever you evaluate a patient, you always evaluate the patient physically first of all. You have to make sure they don’t have a physical disorder that is making them feel depressed. For example, if someone has a thyroid disorder, or a cancer, we often see depression. Or if someone has a substance abuse problem such as drinking alcohol every day, she will be depressed. So, you have to rule out the physical first. Sometimes a person can even be on medications that can make her feel depressed and she doesn’t realize that. Having ruled out the physical causes of depression, you look at the person’s life and obviously if someone has lost a loved one, a parent, a child, a spouse, and the grief is significant, the grief can turn into a depression.

Q: How long does it take for a person to get over losing a loved one?

A: Well, I’ll be honest, if it’s a really severe loss for that person, it typically can take two years to get over it and be truly functioning well. The first year is the most difficult because you have to get through that first birthday of the lost person as he or she is not there to celebrate it with you. You have to get through all the holidays without the loved one, all those milestones, and then you need to get through the date when that person passed away. Then the second year, you slowly get better. Also, someone does not need to have died; it could be a loss of a relationship, a breakup…that can take the same amount of time to get over. If you really loved someone or you were married for a long time and he or she opts out of the relationship, you can’t expect to just get over it in a few months.

Q: Is there a critical time period during that 2-year healing of losing someone where you are most likely to become depressed?

A: Oh yes, the first 3 months. The good news is the mind and heart does heal, that’s why people can lose someone and then remarry or you can fall in love again after a breakup of a relationship.

Q: Besides relationship loss, what other emotional life circumstances are you seeing trigger depression?

A: The one that I am seeing more now in the current economy is people who lose a job and they can’t support their family. And some patients of mine who still have a job are starting to experience fears of losing it with corporate America downsizing.

Q: When a patient comes in to see you and they say they’re feeling depressed, what’s the first thing that you typically do?

A: First of all I take a thorough psychiatric and medical history and make sure the person is sleeping well because I have found sometimes that if I can just correct the sleep problem, the person actually does better the next day and subsequent days. I try not to rush in and give them medication such as antidepressants or anti -anxiety medications. You know, I just say, maybe we could talk a few times, and ask them to start exercising if they’re not etc. … or you can try to work with them on a cognitive therapy level first.

Q: What is cognitive therapy?

A: Cognition means thinking and the way we think can affect what our mood is like, so if you’re worrying if you’re going to lose your job, you are going to feel down and anxious all day. But if you can work with a therapist and try and change your thinking ... try to develop a positive approach to the problem …you could think about the fact that you do have marketable skills, that you do have a good work history, then there may well be another job for you. In other words you try to engage in more positive thinking or cognition.

Q: When do you know that cognitive therapy will work for depression?

A: Here’s the important part: If the person comes in to see me on the first visit and the depressed mood is interfering with the person’s daily functioning. I mean they are so down they don’t even feel like going to work or even if they get to work, they are not concentrating enough, they are not performing. If someone has a clinical, biological depression that is interfering with their life, you want to take action. You can do talk therapy, but anti-depressants will help the person get better faster. Psychiatrists know that the worst risk of untreated depression is suicide and secondly, substance abuse, and we want to avoid those obviously.

Q: How do you decide which anti-depressants to prescribe for a patient?

A: Every patient is different. If a patient is very heavy-set or obese, I’m very careful that I don’t choose an anti-depressant that will put weight on them. Or if somebody is a highly-anxious, agitated person, then I doesn’t want to give her a medication that is going to make her more agitated. So, you try and fit the anti-depressant to the patient profile.

Q: When a patient first goes on an anti-depressant, what is important for them to be aware of?

A: When a patient first starts the medication, it’s important that they stay in contact with his or her doctor. Anti-depressants are a little like beauty creams, maybe you can go to Nordstrom and put a Chanel beauty cream on and you’ll be fine but if I put it on, I’ll break out in a rash. The beauty creams are all good but you have to find one that suits the patient and sometimes it takes some trial and error. So, the first few days to a couple of weeks on an anti-depressant, I ask patients to call me and check in. I want to know if they can tolerate it, are they having any side effects to it. If they can tolerate it, then you push up the dose as far as you can go and the patient will come in and say they are feeling a little better, maybe they ran that morning for exercise... If after, I would say no more than 6 - 8 weeks on an anti-depressant, and they really aren’t doing well yet, then it’s time to change the medication to something else. It wasn’t a good fit for them.

Q: Once you find the right anti-depressant medication, how long can a person be on that drug?

A: I have patients who have taken them for years. If you take a medical history from a patient who has a real biological depression… he or she could have had this depression since 10-11 years of age, then this is a very different depression than a situational one where someone has lost a loved one. If a patient has a long history of clinical depression, then chances are it is something genetic and they probably need to be on an anti-depressant for a long time, just the way a diabetic patient who’s missing insulin needs to take insulin.
So, that’s one scenario.

The second scenario for how long to keep a patient on anti-depressants is this: If someone has been very healthy in their life and hasn’t had any bouts of depression but suddenly lost a loved one or lost their job and they just plummet, I usually ask the patient something like, “How long do you think you’ve been feeling sad?” And if the person says something like 6 or 9 months, then I suggest they stay on the anti-depressant for at least that length of time. That’s how I gauge it. The average time is usually about a year that a person is on the medication. The studies have shown that most anti-depressants, if they work, should be treatment for about a year. If you stop the medication prematurely, the patient is much more likely to have a recurrence of the depression. I always try and take a patient off of anti-depressants but if I get a clinical picture that they have this kind of recurrent depressions which some people do, then I prefer to keep them on the medications just so they can lead their lives effectively.

Q: What about non-traditional ways of treating depression, herbal remedies and alternative treatments?

A: When I was in med school, they didn’t teach us about that, but obviously I’ve learned about it along the way because so many of my patients bring stuff in and ask about it. To be honest, I think if someone has a serious biological depression, they need to be on anti-depressants not on an alternative treatment. I think it’s very nice the patient goes and does yoga or goes to their acupuncturist or takes fish oil or St. John’s Wort, but they don’t work well enough for serious depression.. When St. John’s Wort came out a few years ago, it was pushed a lot as a treatment for depression. The future studies that were done from England show that it’s not good enough for treating moderate to severe depression.

Q: What is your advice for proactively preventing depression?

A: Well, if you have a biological predisposition to depression, such as a family history of depression or mood disorder or a previous episode, I would highly recommend you seek psychiatric care.

Q: Are women more at risk for depression than men?

A: No, it’s an old outdated statistic that women are more depressed than men. Formerly, women sought out treatment for it more than men, and I think that is why it was assumed that women suffer depression more often. At least 40% of my practice is male, often with complaints of depression or anxiety and I am reassured that they are coming in and no longer see it as a stigma to seek psychiatric care.

Q: What is the connection between depression and anxiety?

A: That’s a good question. They often go hand in hand. Sometimes if a person has what we call a generalized anxiety disorder, you know...a worry wart, they worry all the time, you probably have a friend or someone in your family like this, and they make you nervous just being around them. It’s really hard to live that way, so the person often feels very depressed. Or the opposite, let’s say someone is depressed and they’re not motivated to do anything and they start worrying about finances or losing their job because they’re not performing…so you often see both at the same time.

Q: Are there any new treatments for depression?

A: All the time we are seeing newer antidepressant because the pharmaceutical companies are trying to fine-tune the anti-depressants so they don’t have side effects, in particular the side effects of weight gain and decreased sexual appetite. If they could come up with one of those, they’d have an absolute winner.

Q: What if all the anti-depressant treatments you try on a patient aren’t producing any positive results, then what do you recommend?

A: There are those patients where we use combinations of anti-depressants and mood stabilizers. But let’s say it all fails or let’s say the patient is really sensitive to meds, they get side effects all the time, then we use ECT (Electroconvulsive Therapy) and it’s very effective. ECT is a much more civilized procedure than what’s been portrayed in the movies, like “One Flew over the Cuckoo’s Nest”. We only use it unilaterally or one side of the brain. In Cuckoo’s nest, they used ECT on both sides of the brain. So, it’s a much more gentle procedure than it used to be and with much less after-effects…the most significant side effect years ago when they did it on both sides of the brain was that you’d have short-term memory loss but there is much less of that now. Usually you have a series of ECT treatments, between 6-10, and then if the person gets down a little bit a few months later, then they may have a follow up treatment.

Q: If you’ve had an experience with depression, are you then likely to have another bout of depression?

A: Not necessarily. It depends. Some people just have one depression in their life and we can see why, they lost someone, perhaps a job, or suffered a major setback in their life, and we can get them back on track with antidepressants or cognitive or supportive psychotherapy. . And maybe they have a good job, or a family, or children…they have elements in their life that keep them going. The more support networks you have in your life the less likely you are to fall into a serious, clinical depression. However, there are those people who have recurrent clinical depressions since childhood that may require ongoing psychiatric care.

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