Q: Peter you are the founder and medical director of a primary care medical clinic, one that functions as the initial point of contact for patients in a certain geographical area. I understand that your clinic sees over 3500 patients annually. Does your clinic provide treatment for depression or other mental and behavioral health disorders?
PVH: Yes, and we consider it a very important part of our practice.
Q: Some observers are saying that there is an “epidemic” of depression and that depression may soon be one of leading causes of disability worldwide. Recent studies seem to support this prediction. We know, for example, that depression affects 30% of the population in high income countries like the United States, France, and the Netherlands.
Have you seen evidence of an epidemic of depression at your clinic?
PVH: I’ve been in medical practice for 30 years and I believe the epidemic has existed for a long time. What has changed is the dramatic improvement in the ability and willingness of physicians to diagnose and treat depression. In the past, many physicians tended to ignore signs of depression in their patients because they didn’t know how to treat it.
About a decade ago, our clinic did depression screening on every adult patient for several months. The results were startling. Nearly 30% of our patients screened positive for depression. This was a much higher number than we expected. We were shocked to realize how many depressed patients we had overlooked either because they did not complain about depression or because we did not relate their symptoms to an underlying depression.
Another factor in the epidemic is the change in peoples’ attitudes toward depression. Thirty years ago most people saw depression as a stigma. Patients might even argue with me if I suggested that diagnosis. Nowadays, patients will sometimes ask to be evaluated for depression.
Treatment of depression before the 1960s
Q: Before the 1960s and the discovery of antidepressants, what was the main treatment for depression?
PVH: For mild to moderate depression, the main treatment was traditional psychotherapy. This form of treatment was only moderately effective because it focused mainly on helping patients understand old behavioral patterns, but not on helping them change current negative patterns.
Electroshock therapy, rarely used nowadays, was the main treatment for severe refractory depression. Its effectiveness was limited and short-lived, lasting often no more than six months. The treatment sometimes resulted in harmful side-effects, including the permanent loss of long-term memory.
The different types of depression
Q: You mentioned two types of depression, mild to moderate depression and severe depression. Are these the main categories of depression from a medical standpoint?
PVH: Essentially, yes. But severe depression can be a single short-lived episode, or a more longstanding and recurrent disorder. I think it’s helpful to view depression as a continuum, with moderate depression being a midway point between mild and severe depression.
At our clinic, we see mainly patients with mild to moderate depression, people who are still relatively functional and able to work and take care of their families. A person with severe depression is more disabled and has difficulty with such basics as personal grooming, work attendance, and social conventions. About one in six of our patients have severe depression.
Our clinic also treats people with schizophrenia, anxiety disorder, bipolar disorder, and post-traumatic stress syndrome, but depression is by far our most common diagnosis for behavioral health patients.
The main symptoms of depression
Q: What are the main symptoms of depression?
PVH: Anxiety and sleep disturbances are very common in people with depression. In fact, it is more common for people to complain of anxiety or sleep problems than to say, “I’m depressed.” Other common symptoms include fatigue, appetite changes (either lack of appetite or excessive eating), poor concentration, memory problems, and a lack of enthusiasm for life.
People whose depression alternates with edginess, irritability, or mania may have a bipolar disorder, which has a totally different treatment from standard depression.
Q: I understand that depression, especially in its more severe forms, causes changes in the functioning of the brain. Can you explain what the changes are?
PVH: The brain scan of a person who is severely depressed essentially shows inactive prefrontal lobes and an overactive limbic system. The prefrontal lobes are the region of the brain that allows us to concentrate, feel enthusiasm, learn new things, get along well with others, and live without anxiety. The limbic system is the primitive part of our brain. When overactive, the limbic system causes feelings of anxiety, panic, and abnormal body rhythms such as poor sleep or abnormal appetite.
When we look at that same person’s brain scan a year after the depression has lifted, we find normally functioning prefrontal lobes and a quieter limbic system. The normalizing of the prefrontal lobes automatically suppresses many of the negative emotional expressions of the limbic system.
The effectiveness of antidepressant medication
Q: There have been a number of scientific studies questioning the effectiveness of antidepressants as a treatment for depression. Essentially there are two main criticisms: One, that antidepressants used alone produce full benefits in only 30-40% of patients, and two, that the effectiveness of antidepressants is short-lived, and patients end up having to take multiple antidepressants. Based on your experience, is there any basis for these concerns?
PVH: Unfortunately there is. Prescribing antidepressant drugs is too often a quick and easy substitute for developing a comprehensive treatment plan. Antidepressants are best used in combination with the type of supportive behavioral therapy that’s been shown to reduce symptoms of depression and prevent recurrences. At our clinic we try to prepare an individualized program for each patient based on the patient’s level of symptoms and disability.
Q: How does your clinic determine whether or not to use antidepressants?
PVH: The decision to use antidepressants is usually dictated by the severity of a person’s symptoms and how long they’ve had them. Mild symptoms can often be treated without medication. For example, a person with mild depression may only be having minor sleep problems and occasional fatigue. Simple lifestyle changes like getting more exercise, eating a better diet, and drinking less coffee will often eliminate these symptoms.
A person with moderate depression may experience sleep problems, work problems, and difficulties with relationships but still have a certain level of successful functioning in each of those areas. We will use antidepressants to treat people with moderate depression depending on the severity of their symptoms and how long they’ve been present. The more severe and longstanding the symptoms the more likely we are to use antidepressants early in the treatment.
When someone who is severely depressed finally seeks help, he or she is highly symptomatic: often afraid to leave the house, not attending to proper grooming, using alcohol or cannabis to curb anxiety, and unable to work.
When a person’s life is impaired to this extent, we take stronger action, using medication in part to reduce the risk of suicide. Suicide is always a risk with depression but especially when the depression is severe and accompanied by anxiety. Typically we would start both antidepressant treatment and behavioral therapy during the patient’s first visit.
Cognitive behavioral therapy
Q: What type of supportive behavioral health therapy do you use at your clinic?
PVH: We use cognitive behavioral therapy, which works much better for most of our patients than traditional psychotherapy.
In cognitive behavioral therapy there is an emphasis on affirmation, positive attitude, healthy living, good friendships and simple forms of meditation. After about five visits, each 15-25 minutes, with the behavioral therapist, our patients are usually ready to do their behavioral techniques on their own. But they always have the option of returning for “tune-ups” if they are having difficulties.
Patients who are consistent in using the behavioral techniques can successfully phase out of using antidepressants in one to two years and can stay off them indefinitely.
Q: In your last answer were you referring to both moderately and severely depressed patients?
PVH: Yes, but patients with moderate depression are more likely to be able to come off antidepressants in a shorter amount of time. Those with more severe symptoms may need ongoing medication and sometimes multiple medications to maintain good mental health.
Q: What kind of behavioral techniques do you include in your patients’ treatment plans?
PVH: Since people with depression often tend to ruminate over negative events, our behavioral health practitioners train them to watch their thought patterns and to replace negative thoughts with positive thoughts, and to use affirmations tailored to their specific needs.
We routinely give our patients assignments to engage in positive activities such as serving others, practicing optimism, performing acts of kindness, and counting their blessings. We may start with simple recommendations such as showing a positive interest in others by calling at least one friend or family member daily. The studies show that these kinds of activities are effective in reducing symptoms of depression in people with mild or moderate cases. Our experience at our clinic supports the findings of the studies.
We also involve patients in developing a plan to improve their future. The plan involves setting goals and checking in with their therapist at least once a week to assess their progress. One study shows that having positive expectations about the future can even reduce symptoms of severe depression. From brain imaging studies we know that the simple act of setting goals can help activate the prefrontal lobes of the brain.
Meditation: a powerful tool
We also recommend regular meditation. Since meditation strongly activates the prefrontal lobes, it is a powerful tool in the treatment of depression and other behavioral health disorders. Our behavioral therapists teach roughly 80% of our patients with depression some form of meditation as part of their therapy.
Q: I assume that antidepressants, as well as the behavioral techniques you use, also activate the prefrontal lobes?
PVH: Yes. Antidepressants are a chemical means of restoring normal prefrontal lobe functioning. Studies show, however, that modeling positive behavior is one of the best ways to stimulate helpful new activity in the brain.
Q: How widespread is the use of cognitive behavioral therapy in the treatment of depression?
PVH: Today depression is mainly treated in medical clinics such as ours by practitioners using antidepressants as well as cognitive behavioral therapy. The most cutting edge medical clinics all have behavioral health therapists as part of the clinic staff. We’ve had behavioral health therapists working at our clinic for almost a decade.
Our clinic uses an integrated behavioral health model which allows patients to see a therapist and start therapy the same day they receive a diagnosis of depression from a medical practitioner. Other clinics are also beginning to use this model.
Severe depression and cognitive behavioral therapy
Q: In your experience, is cognitive behavioral therapy alone, without the addition of antidepressants, effective for people suffering from severe depression?
PVH: No. Cognitive behavioral therapy usually is not effective because severely depressed people usually lack the motivation to get better or are simply not able to work on changing their thought patterns to any meaningful degree.
Q: What treatment does your clinic provide for patients who are severely depressed?
PVH: We now have a host of highly effective well-tolerated medications we can give for six months to one year to help patients through episodes of severe depression.
Q: What if a person has tried multiple medications and behavioral therapy and is still significantly depressed?
PVH: In that instance we either reevaluate our diagnosis or get a second opinion from a psychiatrist. The recent availability of tele-medicine has allowed us to make frequent use of on-site two-way psychiatric consultations with the patient present.
We refer the roughly 10% of our patients with severe depression whom we aren’t able to help to specialty behavioral healthcare, which involves treatment by a psychiatrist and ongoing traditional psychotherapy, and may last many months.
A new energy-based depression treatment
Q: What new directions or research do you see as the most promising for treating depression, especially severe or recurrent depression, in a primary care setting?
PVH: The most promising new treatment is known as Transcranial Magnetic Stimulation (TMS), a type of therapy that sends short bursts of highly focused magnetic energy pulses to the left prefrontal cortex of the brain. These energy pulses stimulate the areas of the brain linked to depression.
TMS is a 40-minute out-patient procedure that’s administered daily for 4-6 weeks, with minimal side effects. Patients remain awake and alert, and are able to return to their normal activities immediately after the procedure. I think TMS therapy will be used increasingly in the future for severely depressed people who don’t respond to any other form of treatment.
Q: TMS sounds very promising and reflects the energy-consciousness of Dwapara Yuga. Could it also be used for people with moderate depression?
PVH: To date all the studies on TMS have involved people with severe depression. At this time, we don’t know enough about the treatment to recommend it for patients with milder symptoms, particularly patients who have not first tried antidepressants or behavioral therapy. The TMS equipment is also very expensive; until the costs go down, TMS would not be affordable by most clinics like ours. Currently TMS therapy is available primarily in large research hospitals that can afford the equipment.
Depression diagnosis: a trial and error procedure
The ideal for a clinic such as ours would be to offer functional MRI-type brain scans together with TMS. Having appropriate scanning equipment would enable us to make more precise diagnoses and to refine the diagnoses of patients who are not responding to treatment.
Although our clinic uses a detailed questionnaire to screen patients for depression, depression diagnosis remains a largely trial and error procedure based on the patient’s symptoms and observable behavior. There are no blood tests or inexpensive, readily available brain scans to help us make a diagnosis.
Q: Is there any chance the costs of TMS and brain scanning equipment will go down?
PVH: Yes. I’ve seen the costs of other new medical technology drop over time. Our clinic’s first telemedicine equipment cost $70,000 ten years ago. Today you can get the same technology for $9-10,000. The trend with new medical technology is toward making it smaller, more efficient, and less expensive.
Q: Even if TMS becomes more widely available, wouldn’t there still be a need for behavioral therapy to teach patients the behaviors and attitudes that prevent the recurrence of depression?
PVH: Yes. TMS might eliminate the need for antidepressants, but there would still be a need for cognitive behavioral therapy. We’ve found that nearly everyone with depression benefits from learning to meditate and from having someone available to coach them in the behaviors that lead to improved mental health.