The Y in Psychiatry
"The Y in Psychiatry" – a pragmatically endearing podcast talking to the med students, residents, fellows, and attendings of the medicine world about the nuances of psychiatry.
Each episode features focused discussions that explore the intersection of the mental health, medicine, and the human experience.
Together, we'll uncover the hidden "Y" – the compelling reasons, profound insights, and groundbreaking discoveries shaping the psychiatric landscape.
So grab a seat, warm beverage, tune in, and let's embark on this journey to unlock the mysteries of the human psyche, only on "The Y in Psychiatry."
The Y in Psychiatry
E6 - Depression - First Steps - Talk about it.
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Join us on a journey of hope and healing as we delve into the world of nonpharmacologic treatment options for depression. In this insightful podcast, we explore holistic approaches, therapies, and lifestyle changes that offer powerful tools for managing and overcoming depression.
Our Guru’s share their experiences, knowledge, and practical advice. Discover the transformative potential of mindfulness, cognitive-behavioral therapy, exercise, and dietary adjustments. Learn how small changes in your patients routine can have a profound impact on their mental well being.
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Welcome to the Y in Psychiatry,
Dr. Amayo:Hi, this is Dr. Amayo C/L fellow.
Thanh:Where we delve into the intricate nuances of psychiatric topics.
Dr. Handratta:My name is Dr. Handratta attending psychiatrist. I did my residency from University of Connecticut and then I did my fellowship from Georgetown University in consultation and liaison.
Thanh:Each episode features interview style discussions that explore the intersection of the mind medicine and the human experience. Together we'll uncover the hidden why and the groundbreaking discovery shaping the psychiatric landscape. So grab a seat, warm beverage, tune in, and let's embark on this journey to unlock the mysteries of the human psyche. Only on The Y in Psychiatry.
Dr. Amayo:All right, welcome back to the Y in psychiatry. Today we'll be continuing from the algorithm of depression. And just a quick reminder, last time we talked about, why to treat depression, the steps in diagnosing depression, and the first step you want to think about, again, it is your host, Dr. Amayo C/L Fellow, and I am here with my co-host, Dr. Handratta.
Dr. Handratta:Hello guys, how are you?
Dr. Amayo:Attending extraordinaire. And today we'll be talking about how to select a treatment for depression. Dr. H. So what are the first steps do you normally take if you wanna treat depression.
Dr. Handratta:So we all struggle with intimacy. We all struggle with our emotions, right? Oh yeah. Sometimes we cannot express our emotions, though we feel it, right? So psychotherapy definitely helps us to open up and get inside. Into our own emotions because if we understand our own emotions, we can understand our patient's emotions or our friend's emotions or family members' emotions, right? Alright, so now the question that Miracle asked, like what do, what are the steps that we take when we are treating depression, right? So this is not based on any book or on research data. So we basically tailor our treatment depending on the situation, right? The situation that caused the depression. Is it a psychosocial stressor that is going on, or is it biological right? Is a patient having an underlying medical condition that is precipitating the depression or it's actually related to the lifestyle, people basically not sleeping well or drinking a lot of alcohol or using drugs. So it Totally depends upon what is the situation and the circumstance, right? So it's very important to understand that because then you can tailor your treatment and you can see what exactly the patient needs instead of just writing a prescription and sending the patient out. The second thing is, I believe in combining medication management with psychotherapy. So whenever you are talking to a patient about medication management, psychotherapy, make sure that the patient is involved in the treatment, right? Do not tell the patient, this is what I'm going to do. Tell the patient, Hey, this is the information I'm going to give you, and we both are going to work together and you are gonna make the decision. You are gonna be in the driver's seat. I'm going to be actually sitting right next to you and guiding you'cause it's important for the patient to realize that they have the control,
Dr. Amayo:Why does psychotherapy work, or how does it work with depression?
Dr. Handratta:Psychotherapy, I considered it to be the backbone of treatment, because if you do not treat the underlying cause, then using a medication is more like a bandaid, A person has to actually understand actually what exactly is going on, what is causing the depression, or what is making them feel the way they are feeling, because this usually helps you to develop some coping strategies. That basically means that we know from our previous episode on network that in depression, you're stuck in the default mode network, You're ruminating, you are isolating, you're avoiding you are crying. But psychotherapy, what it does is that it usually helps switch the network. Going from a default mode network into a central executive network so that you get control over your life. You change the cognition, the way you think about life, the way you think about psychosocial stressors in your life, right? And that is why psychotherapy is extremely important. So our goal is actually to make the patient self-reliant without medications Now it's totally different if the patient had three or more episodes of depression than according to the research data, they have to be in an antidepressant for the rest of the life, But the first and the second episode of depression, you have a duration, actually, like an approximate duration, how long the patient can continue the medication, and that makes them feel better, saying that they will not be reliant on the medication the rest of their life.
Dr. Amayo:So one of your first steps in picking a treatment for a patient with depression is understanding the factors surrounding it. Like if it's an acute social stressors, involvement of substance, or a medical cause. And then if primary, from social stressors, and mild then you would stress using psychotherapy as it can help in change those neuronal pathways, those automatic pathways and ultimately resulting in patients resulting in a more resilient pathway of the network.
Dr. Handratta:Exactly. and a part of the psychotherapy always should start with psychoeducation, whatever psychiatric disorder you are treating, psychoeducation should be a very important part of the treatment. Because if you're not psychoeducating the patient, then it's basically, I consider this to be a type of psychosocial malpractice, So psychoeducation has to be good.
Dr. Amayo:Why?
Dr. Handratta:Because the thing is that people like to understand what is going on and there are very few providers who sit with the patient and discuss that. For example, if you go to internal medicine, you go to oncology. Other fields of medicine, the physician will sit and describe to them what exactly is going on, right? So the patient has an understanding. Otherwise, what do the patients do? They go on doctor Google, and they basically search things. Sometimes actually they get the right information. Sometimes, many times they get the wrong information that is further going to increase their stress, So it's very important actually to educate because, and then plus you educating somebody about something is more humane, right? You're basically like taking the condition seriously. You're basically telling the patient, Hey, it's not your imagination. that is something biological, which we can treat it right? There's no cure, but we can help you. So I always say actually, like the medication that we prescribe and the other treatment, it's not it's not a happy pill. I usually tell them, it's gonna make you less miserable than how you're feeling now. So giving that right kind of expectation is also very important. That's why psychoeducation plays so such an important role because you don't wanna prescribe when the patient goes and says, Hey, I'm gonna be back to a happy no, you will be actually less miserable. And it's it's the steps that we take. It's a baby step, right? Yeah. Because I do not know what normal is.
Dr. Amayo:So besides, psychotherapy, what else do you keep in mind?
Dr. Handratta:Other things are like exercise. Which, and that is research data on aerobic exercise and its antidepressant effect.
Dr. Amayo:So when you're exercising on being bros,
Dr. Handratta:Yes, I've ex exercise being bros. Being bros is like socializing, right? You are actually getting out of your default mode network and you are actually getting into your central executive network. Because people With depression, there is no bros actually, they're isolating inside their house, So you are absolutely right. So being bros and going out, exercising your, basically engaging your central executive network, right? Socialization is also a very important part, We are to encourage the patients, actually call your family member, call your friends, get out of the house, take a walk, Go babysit somebody's pet or dog because that will you will go with the dog and go for a walk. See people around you, So exercise socialization should be an important part of the treatment, Healthy eating, So I always look at the BMI. I talk to the patients not telling them what to do, I don't want to patronize the patient, I ask them like, what does your eating lifestyle looks like? And then actually telling the patient that we all actually don't know what healthy eating is. Is it okay for me to actually refer you to see a nutritionist, Because we have all, everything that is available we don't utilize the resources that we have around us. Because we know that obesity is pretty common in patients who have psychiatric disorders, and a lot of our medications can cause metabolic side effects. So this is, so prevention is always better than cure, So this is a preventative approach Then if the patient has comorbid attention problems, Refer the patient for executive function coaching, which helps them with the executive functioning. Again, you are recruiting the central executive network.
Dr. Amayo:What is that? Executive function coaching?
Dr. Handratta:So executive function coaching is basically, these are life coach see patients with attention deficit disorder, who usually teach them organization and planning skills, how to manage your time, how not to be impulsive, So that helps to organize the life, right? So executive function is nothing but planning and organizing. Planning for the future. And sleep is extremely important. That is neglected by many because the residual stuff, after you treat depression is basically cognitive impairment and insomnia, Sometimes as you treat the depression, the insomnia gets better, but many times insomnia is totally separate than the depression, so you have to pay attention to that. So educating the patient about the circadian rhythm, why is it important to have a good sleep schedule? And in this electronic age, we are always actually on our electronic system, So the sleep wake cycle is disturbed when you go out. Everything is so bright at night that will actually like disturb your sleep wake cycle, They say that people who are in a rural areas have a better sleep wake cycle because when you look at the sky, it's dark. Yeah. City, if you look at the sky, it's bright, Because of all the light. So it's important actually to educate about a good sleep wake cycle, right? So these are actually like healthy lifestyle choices.
Dr. Amayo:So you're saying exercise, socialization, sleep optimize all those. And this is all before you even start thinking about psychotherapy and pharmacotherapy.
Dr. Handratta:There is plenty of other things. I have a list actually of things that I basically do before I start the treatment because my psychotherapy has started actually the time I start seeing the patient. So I've already started psycho education. And these are the things that you will not see on the internet actually. And these are the things that we do not focus on. Most of us are actually have such a busy schedule that we just write a prescription and send the patient out. And when you educate about these things, a lot of times patients want to see you again. Because you are not one of those pill pushers. Another things actually that I want to make sure is to rule out sleep apnea. This is missed a lot of times, Always ask the patient about sleep apnea. So the best way to do it is do a STOP BANG score. Very easy to do pretty quick, and the scores will basically tell you whether the patient is mild, moderate, or severe apnea. And then you can refer them to sleep study. And the sleep specialist, when they look at the stop bank score, they will like, okay, so this like most likely patient has sleep apnea, Or you can actually use pulse oximetry. So that's an easiest way of actually knowing whether you have sleep apnea is pull the pulse oximetry, it records your oxygen saturation on your cell phone. So when you wake up, you can see how many number of times you've had desaturation put that data in your referral, send it to the sleep specialist, So sleep apnea is very important to treat because if you don't treat sleep apnea, it can lead to treatment resistant depression.
Dr. Amayo:Why?
Dr. Handratta:What happens is that when people have sleep apnea, they have micro episodes of waking up multiple times in the middle of the night, So you don't have a good consolidated sleep. And most of our memory formation actually happens. A consolidation happens in the non-REM sleep, There's also a data which shows that when people have insomnia, there's an increased risk of amyloid beta deposits in the brain, what happens is that your neurons are active during the daytime, but when you're sleeping, your neuron go to sleep. But your glia, the astrocytes become active. Those are the cleaners. So what they do is that they clean up all the gunk that is accumulated during the daytime that is produced by the neurons. You don't clean that up. You cause pre-radical damage. So that's why sleep is important. So your glia can actually work. So these are some of the things that I talk to the patient about, and when patients ask me questions I describe, I explain to them as to like, why is it important? Because there's always a why. That's why we made this particular podcast. right? Why in psychiatry, And then like when you are seeing patients always use scales, scales are extremely important because it tells you what the baseline looks like and how they are responding to the treatment.
Dr. Amayo:So scales for the depression or for to rule out other illness.
Dr. Handratta:It's actually for depression. So what's the scale that you use Miracle for when you're seeing patients with depression?
Dr. Amayo:PHQ nine is usually what I use. Yeah.
Dr. Handratta:And that's like a scale. It's patients can actually do it by themselves, right? Yeah. So PHQ nine is a great tool to use, but at the same time, I also want the patients to do a mood disorder questionnaire or a rapid mood screener, right? Because that will give you an idea whether you need to go into detail and ask the patient about mania or hypomania, So if the rapid mood screener or mood disorder questionnaire is negative, then you're ruled out mania or hypomania. But if it's positive, then you can go in detail. So at least you know whether you need to focus on mania hypomania, right? Because the treatment completely changes. And as we talked about in the previous episode, every five patients diagnosed with major depressive disorder in a primary care office, one will have undiagnosed bipolar disorder, And most of the bipolar disorder, the present with depression. So they usually get missed. Then the depression scale will vary depending upon what are you treating. For example, a patient with schizophrenia, you can't use PHQ nine because schizophrenia patients have negative symptoms, right? PHQ nine actually talks about neuro vegetative symptoms. So you use something called Calgary Depression Scale in patients with schizophrenia All these are available on the internet and it tells you exactly how to score it, Patients who have postpartum depression, you can use PHQ nine, But the scales that is most commonly used is the Edinburough Postnatal Depression Scale, And your treatment depends upon what the score is. The next one is patients who have H I V, they have a lot of neurovegetative symptoms. So you basically use something called Beck depression inventory for primary care. Which basically just does not focus on the neurovegetative symptoms. More on the affective symptoms. Geriatric population, you use geriatric depression scale because sleep, appetite weight is a problem in the geriatric patient, even if they don't have depression. so it basically just focuses on the affective symptoms. Last but not the least always try to differentiate apathy from depression. And we'll talk about apathy in one another podcast because there are two different conditions and SSRIs and SNRIs can make apathy worse. So use something called apathy, evaluation scale.
Dr. Amayo:Okay. So when treating depression, make sure you utilize your scales and depending on the population, depending on comorbidities use the right scales and do not forget sleep because we need sleep during our sleep. That's when our brain gets to clean up and not sleeping leads to a lot of risks to include worsening depression and giving you treatment resistance, depression. Okay. I think that was a very good beginning on how we treat depression and other things we can include besides, Zoloft. Thank you very much. And this has been the Y psychiatry.
Dr. Handratta:Perfect. Thank you. My brothers and sisters.
Katrina:Thank you for joining us on today's episode. our tireless team is already hard at work, cobbling together another potpourri of fascinating discussion for next week, so be sure to tune in, visit our website and our podcast feed and let us know your thoughts on the episode. Subscribe so you don't miss our releases every Wednesday. Until next time, keep smiling, keep shining, and stay curious.
