Spreading Hope!

By Matt Goldenberg
D.O.

@docgoldenberg 

“You treat a disease, you win, you lose. You treat a person,
I guarantee you, you'll win, no matter what the outcome.” 

I whole-heartedly agree with that statement. However, I
cannot take credit for those words. Those are the words of Robin Williams, or
more specifically, the words of his character in Patch Adams.



I want to discuss the disease called depression. I will start by first
discussing the diagnosis and the signs and symptoms of depression. I will then
follow up with my thoughts on the various treatment options for depression and
the strategies I employ with my patients to improve their outcomes. None of my
thoughts and suggestions should serve in place of a formal consultation with a
mental healthcare provider. However, I hope shedding light on mental health
diagnoses like depression will lift the veil and social stigma on these chronic
diseases that impact so many people.



Psychiatry has come a long way in the last decade. This is a time of continued
discovery and increasing public awareness. The leaders of our professional
organization, the American Psychiatric Association (APA), have suggested that we
as mental health professionals are under a microscope. I agree that we are
and I also strongly believe that we are up for the challenge. School shootings
and celebrity suicides and overdoses have increasingly put a focus on mental
health. Psychiatry has significantly improved the outcomes, treatment options
and the prognosis of patients with mental illness. However, we still are unable
to decrease the prevalence of the diseases we treat or prevent them. We know that
the brain changes during an episode of depression and our treatments help it to
return to normal (see the image below). Although we are getting closer, we
still currently do not have widely accessible blood or imaging tests that can
confirm our diagnosis or localize the area of disease.

I can say with certainty, however, we are able to accurately
diagnose patients. We are able to identify medications, psychotherapies and
other treatments that patients with a specific diagnosis or cluster of signs and
symptoms often benefit from. There is strong evidence that our treatments
decrease symptomatology and disability and improve quality of life, clinical
outcomes and a patient’s prognosis.



Psychiatrists are trained to view the patient as a “whole person”. Psychiatry
is a field of medicine whose assessment by definition includes all of the
biological, psychological and social aspects of a patient’s life. We listen for
the psychological and social factors that can contribute to disease.
Oftentimes, the “whole story” can be more telling than only focusing on
specific symptoms of a given disease. There is a saying, throughout all fields
of medicine, that “most patients have not read the textbook.” In other words,
patients usually do not present exactly as the textbook says they should.
Stress and psychological factors can mimic chest pain, shortness of breath,
gastrointestinal problems and a whole host of other diseases. If we do not step
back and get the whole story, we can miss the root cause or the exacerbating
factors of many manageable diseases which are of the mind.



Many of the diseases we treat, such as depression, are chronic illnesses which
require lifelong treatment. Our treatments can improve a patient’s mental
health and coping skills and decrease their symptomatology and substance use.
We know through decades of research that these are modifiable risk factors for
suicide. Therefore, Psychiatrists have the training and tools necessary to
decrease a patient’s risk of attempting suicide. Our treatments have the
potential to not only significantly improve the lives of our patients, but also
the lives of their families and everyone who comes into contact with them.
Anyone who tells you otherwise is misleading, misinformed or both.

I
hope this information and the blogs to follow will give you hope. Mental
illness can include symptoms which can be devastating and complications which
can be life-threatening.
However, it is important to state again, these are treatable diseases. If you
or someone you know, would like to talk to someone, call your primary care
doctor or your insurance company for a referral to a Psychiatrist. A true
multi-disciplinary team also includes therapists, psychologists, nurses and
social workers. You are never alone. You can call the national suicide helpline
24 hours a day, seven days a week (1-800-273-TALK (8255) or visit www.suicidepreventionlifeline.org).
There are also local crisis lines likely available in your area and are an
internet search away. If you are ever feeling unsafe, or fearing for the safety
of a loved one, you can call 911 or go to the nearest emergency department.

It is time for everyone to understand that there is no shame in getting help
for depression, much as there is no shame in getting help with diabetes or high
cholesterol. Even if you have never suffered from depression, there is
a lot you can learn.

Together we can raise awareness and spread truth and hope. I know that if we
spread knowledge, and ignore the misinformation, we will overcome the
complacency and ignorance that is so pervasive today. That is how we can best
honor those we have lost. That is how we can best prevent the next death from
mental illness and addiction.

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How does your primary care doctor coordinate with your psychiatrist?

By Pierre
Gingerich-Boberg, Medical Student

Reviewed by Claudia
Reardon, MD



I’m stuck in behaviors
that are making me unhealthy.  My smoking
makes my asthma worse, and I don’t want to end up with emphysema like my dad.  I smoke when I’m anxious, and my finances, my
teenager, my boss, and my increasing weight all make me anxious.  Now to top it off, my chronic headaches are
getting worse.  My problems are physical,
but I know they’re also mental.  But the
idea of seeing a psychiatrist makes me even more anxious!  What should I do?



Patients need primary care doctors who can comprehensively
address the varied aspects of their physical and mental health. Health systems
are starting to recognize that multi-disciplinary teams (sometimes called patient-centered medical homes) can be
an effective way to provide integrated
care.  How might this look for our example
patient?

First, it’s worth noting that traditional primary care doctors
already spend a lot of effort helping patients with a wide spectrum of behavior
issues.  We saw this for our example patient.
 Her anxiety is an example of a classic mental health problem—others
might be depression, panic attacks, and addictions. Primary care docs refer some
of these patients to psychiatrists, but primary care docs are treating the
majority directly.  Our patient’s
headaches are likely a functional
ailment. Like irritable bowel syndrome and general aches and pains,
headaches are real problems that often defy simple solutions.  Standard treatments focus on limiting symptoms
while helping patients cope with the stressors and psychological distress that often
contribute.  Finally, our patient faces
problems with health-related behaviors including
tobacco use, diet, and stress management. 
These and other common behaviors are hugely important for the development
of chronic diseases.  

Our patient’s picture might seem complex, but primary care
doctors face such complexity (and more) every day! Frankly, patients often are
dealing with too much for their doctors to address optimally in a 15-20 minute
time slot. One approach is to triage—to ask what’s treatable and doable, and
what can wait until the next appointment. The limited time
available for counseling tends to push primary care doctors toward relying on
treatment with psych meds. A second approach is to refer the patient to
a psychiatrist.  But psychiatrists in
many communities are spread too thin, so patients often wait weeks or months
for an appointment. Then there’s stigma--our example patient’s anxiety around
psychiatric care is actually pretty typical. 
This helps push up no-show rates for first visits with a psychiatrist to
30 or 40%.  It’s no wonder that careful
studies show that only a fraction of the mental health problems in our
communities are ever diagnosed, and fewer still are adequately treated.

A third option returns us to the medical
home concept.  At the VA and increasingly
in federally qualified health centers (FQHCs), mental health services are being
brought into the primary care setting. 
Here, behavioral health consultants
(BHCs) share space with primary care doctors. 
These are generally psychologists or social workers, that is,
non-physicians. BHCs’ schedules are intentionally left mostly open, so that they’re
available to see patients immediately after a non-threatening ‘warm handoff’
from the primary care doc.  The BHC can offer
expert counseling for the patient, and advise the primary care provider on
diagnosis and treatment.  BHCs arrange
for a small subset of their patients to get a subsequent visit with a psychiatrist
(a specialist physician), who is also in-house. 
 All the BHC patients get
systematic evaluation and follow-up by phone or with visits to make sure their
needs don’t fall through the cracks.

When a behavioral health consultation system is in place,
problems of waiting times, missed appointments, and incomplete records are
eliminated for most behavioral health visits. 
Primary care docs have more time to focus on medical issues, while
getting the expert consultation they need to optimize behavioral health care
for their patients. Finally, because most behavioral issues can be addressed efficiently
by BHCs, specialty psychiatrists are not so swamped, and waiting times can be
greatly shortened for the small group of patients needing psychiatric care beyond
what can be managed in the primary care setting.
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Depression & Cancer

By Brad Zehring, DO @DrZehringDO

“Cancer can take away all of my physical abilities. It
cannot touch my mind, it cannot touch my heart, and it cannot touch my
soul”  - Jim Valvano

But, what
happens when it does?

Depression
is a multifactorial disorder that requires acknowledgement of the biological,
psychological, and social aspects of a person’s life. Professionals in the
mental health community describe this as the biopsychosocial model. It provides
an understanding of the factors influencing a person’s mental and physical
state of being.

When mental health professionals talk about depression they
often do so in regards to Major Depressive Disorder (MDD). According to DSM 5
(Diagnostic and Statistical Manual of Mental Disorders), 5 out of 9 criteria
are needed to diagnose MDD. It requires a depressed mood or anhedonia (lack of
enjoying what was previously enjoyed) for greater than 2 weeks including:
disturbances in sleep, guilty/hopeless/worthless feelings, poor concentration,
low energy, changes in appetite (weight loss or weight gain), psychomotor
agitation or retardation, and suicidal ideation.

Depression affects your entire body. But, the physical
aspects of depression are often overlooked. It is common for people with
depression to experience weight changes, digestive problems, headaches, back
pain, muscle and joint pain, and disruptions in sleep cycle. Many symptoms that
are present in cancer.

Depression has been linked with many health problems,
including cancer. Cancer is a heavy word. The enormity of the word brings many
images to the forefront of our imagination: radiation, chemotherapy, losing
hair, sickness, weakness, and death - among others. There is so much symptom
overlap between cancer and depression it can be hard to recognize the etiology
of the symptoms.

It is important that health care professionals, family
members, and other caretakers
are vigilant with a person’s mental well being after they are diagnosed with
cancer. Even if a person has never experienced depression previously, their
risk of depression is increased when they find out they have cancer. Research
shows that the incidence of depression increases proportionately with the
cancer’s progression. It is believed those with depression have increased
likelihood of depression because of increased immune response (cytokines)
within the body.

It is important not to assume that someone with cancer has
an appropriate depressed mood due to his or her circumstances.  This is why it is important to screen for
depression in those diagnosed with cancer. Screening for depression can help
“tease out” symptoms related to depression and symptoms related to the cancer. Treating
depression in patients with cancer can help them focus on their treatment and
have the motivation to do everything needed to possibly achieve remission.
Proper treatment gives them the ability to focus on their future. Cancer alone
is enough, but when combined with untreated depression the results can be
deadly.

After recognizing depression in someone with cancer, there
are ways to treat depression in parallel with cancer treatment. There are two
forms of treatment. One involves medication and the other involves
psychotherapy, or talk therapy. The typical medications for depression are
antidepressants like Selective Serotonin Reuptake Inhibitors (SSRI) and
Serotonin and Norepinephrine Reuptake Inhibitors (SNRI). These medications have
been around for a long time and are generally well tolerated. They take
anywhere from 2-6 weeks for clinical efficacy. These medications should be
monitored with cancer treatment, as there can be drug interactions and side
effects that may not be present in someone taking these medications without
cancer. In addition to medications, psychotherapy can be effective. More
specifically, Cognitive Behavioral Therapy (CBT) can help people change their
negative thoughts about cancer and their future. For the most efficacious
treatment a combination of both should be implemented.

Cancer is a serious illness and a well-developed
multi-disciplinary approach is necessary to best treat the patient. Cancer can
cause a lot of different disturbances in physical and mental health. It is
important to have health professionals, like psychiatrists
and psychologists, part of the treatment team to ensure proper treatment of the
whole patient.

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How Psychotherapy Changes the Brain

By Serina Deen, MDMPH



When I first see patients for evaluation, they often tell me
that they’ve debated starting a “biological” treatment such as medication,
versus a “psychological” treatment such as psychotherapy. I’m happy to report
that as brain imaging technology advances, we’re finding that this distinction
may be obsolete. 

Psychotherapy is also “biological” in that it can lead to
real functional and structural changes in the brain.   In fact, sometimes psychotherapy and
medication produce surprisingly similar changes in the brain.  We still have a lot to learn about the topic,
but below are some examples of what researchers have been finding so far.

Functional Changes in
the Brain:

In one study, researchers at UCLA found that people who
suffered from depression had abnormally high activity in an area of the brain
called the prefrontal cortex.  Those who
got better after they were treated with a type of therapy called interpersonal
therapy (IPT) showed a decrease in activity in the prefrontal cortex after
treatment.  In other words, IPT seemed to
“normalize” brain activity in this hyperactive region.



Another study looked at people who have obsessive compulsive disorder (OCD), who tend to have an overactive area of the brain called the
caudate nucleus.  Treatment with a type
of therapy called cognitive behavior therapy (CBT) was associated with a
decrease in the hyperactivity of the caudate nucleus, and the effect was most
evident in people who had a good response to CBT.  In other words, the better the therapy seemed
to work, the more the brain activity changed.

Changes in Brain
Volume:

People with chronic fatigue syndrome (CFS) suffer from debilitating
fatigue.  People with CFS tend to have a
decrease in a type of brain tissue called grey matter in the prefrontal cortex
of the brain.  Researchers in the
Netherlands gave people with CFS 16 sessions of CBT, and found significant
increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients
were able to “recover” some gray matter volume after CBT.

Similarities and
Differences to Medications

Psychotherapy sometimes seems to work in similar ways as
medications, and other times appears to have different mechanisms of action.

In the study mentioned previously about people with
depression, both IPT and the antidepressant paroxetine (Paxil) showed a
decrease in prefrontal cortex activity.  And
with OCD patients, both CBT and the antidepressant fluoxetine (Prozac) produced
similar decreases in activity in the caudate nucleus. 

However in a different study, the antidepressant Venlafaxine
(Effexor) produced changes in different parts of the brain than IPT in
depressed patients.  This shows that there
is variability in how different treatments work in the brain.

How Psychotherapy
Produces Brain Change

We now know that the brain keeps changing, even after we
become adults.  Learning leads to the
production of new proteins, which in turn can change connectivity in our brains
in a process called neuroplasticity.   Indeed, researchers in Germany showed that
certain neurochemicals involved in neuroplasticity increased in depressed
patients who got better after a course of interpersonal therapy. 

Picking a Treatment
that Works Best for You

Even though we know that both medication and psychotherapy
can change our brain, we still have a long way to go in learning exactly how
that happens and when to use what treatment. Given a specific mental illness,
sometimes medications work best, sometimes psychotherapies are the best option,
and sometimes it’s a combination of the two. 
In addition, there are different types of psychotherapies that work for
different illnesses, just as there are many different types of
medications.  If you’re considering
seeking help for mental illness, it would be helpful to talk with a trained
professional about what would work best for you. 





Read tips on what to expect during your first visit with a psychiatrist  

"Let's Talk Facts" brochure on Psychotherapy

Brain Awareness blog post from NIMH Director Tom Insel, MD

APA Releases List
of Five Uses of Psychiatric Medication to Question

Six tips for talking to your doctor about medication

For more information about psychotherapy

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