Exploring the Realm of Mental Health: Understanding Depression and Treatment Options

Dr Gavin Nimon: 0:28

Did you know that one is 16 Australians suffer depression with over double that incidence suffering anxiety, both conditions are very common and affects social interactions, working relationships and quality of life. These conditions are saying that all medical professionals should be aware of. Today we discuss depression and anxiety within Australia with Psychiatrists. James Hundertmark. James is a Private Psychiatrist working at Ramsey clinic in Adelaide. He Trained at the Repatriation hospital in South Australia. And is past head of the consultation, liaison psychiatry team at the Flinders Medical center and the clinical director of mental health at the Queen Elizabeth hospital and the Flinders Medical centre. He served two terms as chair of the South Australian branch or the college of Psychiatrists and is winner of Margaret Tobin award in 2007 for promoting mental health in a positive way. Join us as we speak to James about this critical aspect of Australian public health. G'day and welcome to Aussie Med Ed, the Australian medical education podcast, designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field. I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and I'm broadcasting from Gardaland. I'd like to remind you that this podcast podcast players and is also available as a video version on YouTube. I'd also like to remind you that if you enjoy this podcast, please subscribe or leave a review or give us a thumbs up as I really appreciate the support and it helps the channel grow. I'd like to start the podcast by acknowledging the traditional owners of the land on which this podcast is produced, the Kaurna people, and pay my respects to the Elders both past, present and emerging. I'd like to remind you that all the information presented today is just one opinion and that there are numerous ways of treating all medical conditions. Therefore, you should always seek advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today. Please speak to your GP or seek assistance for help organizations such as Lifeline in Australia. Well it's my pleasure now to introduce Dr. James Hundertmark. He's going to talk to us about depression and anxiety and the issue that occurs in Australia. Welcome, James.

Dr James Hundertmark: 2:28

Hi Gavin, good to see you today.

Dr Gavin Nimon: 2:30

Well, thank you very much for coming on Aussie Med Ed. It's great to have you on board. And I'm looking forward to hearing about this really important topic. Perhaps we can start off, first of all, talking about how important depression and anxiety is in Australia.

Dr James Hundertmark: 2:42

They are two separate conditions but it's often the case that people with depression have anxiety symptoms. So with a significant depressive illness, it's about 70 percent of people who also have comorbid anxiety. But certainly using the DSM 5, which is the current version of the classification system we use we classify the two conditions as being quite separate. So we've got a number of conditions coming under the depressive spectrum and a number of conditions under the anxiety banner.

Dr Gavin Nimon: 3:19

And how do you actually classify these conditions?

Dr James Hundertmark: 3:22

If we wanted to go strictly by the classification system, in Australia we use the DSM. The current version is actually called the DSM five tr, so that's the latest version of the DSM five. The TR stands for text revision and the DSM system is almost like a cookbook method for diagnosing mental health conditions. So it will list off the specific features. And then, for example, with a major depressive disorder, you'll need to have five of the eight symptoms that it lists under the heading for major depression. So it's pretty specific in that you need to have so many of a list of symptoms to warrant the diagnosis. By and large, under the anxiety heading, it's a little bit simpler, and there are fewer features to... Warrant the diagnosis. So the anxiety heading has got Panic Disorder, Generalized Anxiety Disorder just a straight Anxiety Disorder. And also the simple phobias come under that heading too. And OCD, we used to think about as being under the anxiety heading, but that's under a separate heading for most of us now, Obsessive Compulsive Disorder.

Dr Gavin Nimon: 4:46

So we'll start off with how patients may present with depression and always thought of depression myself as a endogenous version or a reactive depression but perhaps you can explain the different classifications of it

Dr James Hundertmark: 4:57

so I might just start by saying we view anxiety and depression as what we call high prevalence disorders. And that means that they're very common in the community. So anxiety, depression get into that range of one in five. So they're really common in the community up to 20%. And when it comes to depression itself. Yes, we tended to, in the past, think about those two different types of depression, where we talk about an endogenous depression, which was like a depression coming from within, versus a reactive depression. in response to a particular stressor. These days under the DSM system, we don't strictly classify endogenous and reactive. It's more what we call a major depressive disorder and that's pretty much like the old fashioned endogenous depression. Or what we might call now a biological depression. So it's driven from within and it's what a lot of GPs might sit with their patients and talk about as a neurotransmitter imbalance. So these days a lot of GPs will sit with patients and say You've got a deficit of serotonin, and if I give you this serotonin acting antidepressant, that'll increase your levels of serotonin and help to balance out your mental state. But so if we look at the DSM 5, on the one hand, there's the major depressive disorder, and it's got those eight symptoms. And broadly speaking, they're things like change in appetite, change in weight, low energy levels, lack of pleasure in activities, loss of interests, poor memory and concentration, pervasively depressed mood, and then some suicidal thinking. So it's those symptoms that indicate you've got a biological depression. And within the DSM 5, there's also... A category of what we call melancholic depression, which is an even more severe biological depression. And in a sense that reactive term lives on in the DSM 5 in that we've got a category of conditions which is referred to as adjustment disorders. which is basically an individual adjusting to a particular stressor and those adjustment disorders are classified according to the symptoms that come with the adjustment and one of them is an adjustment disorder with depressed mood. So if you like that reactive depression diagnosis lives on in the DSM 5 under the term adjustment disorder with depressed mood. Also include things like adjustment disorder with Anxious with anxiety then there's an adjustment disorder which is a combination of anxiety and depressed mood and a couple of other adjustment disorders in there but again within that depressive heading the DSM tends to have kind of a, it's almost like a waste basket category where if you If the symptoms don't fit the specific headings, there'll be an adjustment, so a depressive disorder, not otherwise specified. So you can have this unspecified depressive disorder if the symptoms don't meet. the criteria for a major depressive disorder. And one of the other headings broadly speaking under depressive disorder is if the patient has a bipolar disorder and they're in a depressed phase of a bipolar disorder. And, by and large, a depressed phase of a bipolar disorder is a much more severe depression than major depressive disorder. And we, not to try and complicate things too much, but we tend to talk about either A unipolar depression, which is that person who just gets depressed and goes back to the baseline, versus a bipolar depression where the person will get depressed, but also sometimes go above the baseline and have an episode of Mania, or a lower phase of mania, which we call hypomania. So there are a few categories there underneath the heading of depressive disorders in the DSM.. Honestly, classification in psychiatry is always a little bit arbitrary. But, for whatever reason, we've come to use this American system, the DSM system. And, It slots people into these little diagnostic categories mean, one of the important things in thinking about A major depressive disorder versus an adjustment disorder with depressed mood comes into the treatment perspective in that a major depressive disorder is going to be a lifelong condition. You're going to have relapses and remissions where you get back to the baseline. And also for that kind of condition, we're much more wedded to thinking that antidepressant medication will help that patient. Whereas an adjustment disorder tends to be a milder illness, people tend to gradually pull up out of that, often without any tablets and often just with a bit of counselling or a bit of supportive psychotherapy, people will get back to the baseline with an adjustment disorder.

Dr Gavin Nimon: 10:41

right. And then with severe depression I believe you also get psychosis attached to it as well, and that's probably more common in the bipolar disorder elements, is it.

Dr James Hundertmark: 10:50

It is more common with bipolar depression, but certainly with a straight major depressive disorder, which is not bipolar, a straight unipolar depression, you can get psychotic features. And this will commonly be things like people feeling that there's something physically wrong with them. People will feel very guilty, like pathologically guilty. Sometimes people will feel dirty and like they can't get themselves clean. So it's where your thinking starts to fail, if you like, and head into psychotic territory. And this actually raises from a treatment perspective, the issue of ECT of what in the old fashioned days used to get called shock treatment. And for patients who've got really severe depression, that's becoming psychotic. Oftentimes, ECT is a really good treatment for that condition and it's going to get the patients better more quickly than persisting with a whole different range of antidepressants and chopping and changing between tablets.

Dr Gavin Nimon: 12:00

So looking at the major depression causes you've said it comes from within and the general practitioner might describe it to a patient as being associated with a chemical imbalance. But obviously there's a lot of polypharmacy that occurs in people all the time and some of these medications we use do actually affect neurotransmitters themselves. Is there any associations with some medications that can lead to a depression type symptoms as well?

Dr James Hundertmark: 12:24

Yes, certainly there are some medications and some quite commonly used medications that can Exacerbate depressive features or sometimes cause depressive features Probably one of the most common ones would be steroid medications So steroids can make people go quite flat or alternatively large doses of steroids can make people go really high in their mood state, and I've seen a lot of people in the general hospitals, say on a medical ward, who are getting really large doses of steroids, they'll have an episode of mania. Where they'll really become really quite unwell. Be up all night, having all sorts of strange ideas, get very paranoid. And that's often caused by large doses of steroid medications. Maybe for rheumatological diseases or renal issues. All sorts of general medical things.

Dr Gavin Nimon: 13:21

Okay, what about the illicit drugs? Do they have an association with depression as well?

Dr James Hundertmark: 13:26

Yeah they certainly do. And I think really this is one of the things that we've identified with marijuana more and more as the time's gone past. That the chronic use of marijuana, as well as causing what we refer to as an amotivational syndrome, also worsens anxiety and depression. So we know that marijuana Causes issues with anxiety and depression., One of the particular things with cannabis or marijuana is that there's a certain proportion of the population who've got a vulnerability towards psychosis. And there's one group that don't have a vulnerability to psychosis and one group that do. And for those people who do have the vulnerability, if they use cannabis, they'll get psychotic. And for some of those people, they'll develop schizophrenia and they'll never recover from that condition. So that's a pretty clear bit of understanding that we've got about cannabis and psychosis now.

Dr Gavin Nimon: 14:33

Right that become a depression type of psychosis or is it just generalised schizophrenia

Dr James Hundertmark: 14:38

oftentimes, it's initially diagnosed as a substance induced psychosis, but it often, quite often, goes on to be like a straight schizophrenic illness, and that patient develops a schizophrenia which is often lifelong. It really flags that, for some people, cannabis use is really bad, and causes really bad psychiatric outcomes.

Dr Gavin Nimon: 15:06

What's the general sort of route that people tend to take when they suffer depression and for the average person you might see?

Dr James Hundertmark: 15:13

So usually first port of call is the general practitioner and general practitioners are very well equipped to diagnose and treat a major depressive disorder. So sometimes the patient will come and say, That they're feeling flat and sad. Sometimes it might be in response to a particular stressor. A common thing is relationship issues or relationship breakdowns would take people along to the GP. It's also worth saying that sometimes people can present on a number of occasions with physical symptoms. They might have. back pain, or they might have other sorts of physical symptoms, and they don't actually report depressive symptoms at all. And it's only after the GP goes through and screens for those symptoms that we were just talking about those eight symptoms from major depressive disorder, and they can see that the patient actually is depressed. And there then might be a conversation between the patient and the GP to try and get them to understand that they're suffering from a depressive illness. And the next thing that's important for GPs is to do a general blood screen to pick up on some of the issues which are physical health issues which can cause a depressive illness. And the common ones are things like low thyroid function or vitamin abnormalities like vitamin B12 deficiency or even a really bad vitamin D deficiency could cause a depressive picture. So it's important to do those baseline screens. Usually they'll come back normal, but it's important to do them, and then you'd get on into treatment. And certainly if the flavour of the depression was more like a major depressive illness, GPs would be starting an antidepressant medication. And the commonest ones these days are those serotonin acting antidepressants. And I gather the most popular one in the market at the moment is a drug called Esitalopram, which is about the sixth in line. Originally we started out with the drug Prozac quite some years ago, which was very popular and very widely known in the community. And now we're on to the sixth iteration of those serotonin acting antidepressants.

Dr Gavin Nimon: 17:40

Now I believe there's also can be some issues with those serotonin and antidepressants as well with some drug interactions. And I believe one of them is one of the ones I might use quite regularly for as a pain relief in the form of tramadol is that correct?

Dr James Hundertmark: 17:52

Exactly right. Yep, so there's a condition known as serotonin syndrome, which is where you get an interaction between various drugs which leads to too much serotonin in the system and people get quite unwell physically with that condition. And so because Tramadol's got a serotonin action in it, the way it works, that does cross react with some of these serotonin acting antidepressants.

Dr Gavin Nimon: 18:17

So moving on from the GP using medications, are there other modalities you might use with someone suffering from depression as well?

Dr James Hundertmark: 18:26

Yeah, so it's often important to involve a psychologist, and so GPs have the ability to do what's called a GP mental health care plan, which allows patients to access psychologists at a slightly lower cost, but certainly it's sensible to involve a psychologist and just spending a little couple of minutes on psychology. Psychologists are trained and certified to various levels. So You could do a three year degree in psychology and practice as a psychologist. You might do an extra fourth year honours in psychology, but really the best qualified psychologists have a clinical master's degree, so for that they'll do the three years. For one year honours and then another two years of supervised training and end up with a clinical master's degree in psychology and they're the best qualified psychologists. And normally for someone who's got a significant mental health condition . I think it's important to use a clinical psychologist

Dr Gavin Nimon: 19:36

And what would that involve then?... Dr James Hundertmark: Usually, GP mental 10 sessions and then patients might get a second mental health care plan. So it's often the case that 10 sessions is enough for of an average depressive illness so they will use to be a specific psychotherapy technique. There's a kind of a general type of psychotherapy we refer to as supportive psychotherapy, which is where you talk over your issues, you talk about what alternatives you might use to deal with a Particular problem is you might reflect on things with the psychologist. You might get reassurance. So that's the first type of supportive psychotherapy. Then there's this expression a lot of people use now, . And what that stands for is Cognitive Behavioral Therapy. But really I like to split the C from the B. And so you've got Cognitive Therapy, which is focusing on the thoughts that you have in your mind. And the Cognitive Therapists would say that depression is caused by a whole lot of negative thoughts that get stuck in your head, that are swirling around. And they make you see the world around you as very negative. You feel very negative in that world. And when you look ahead to the future, it seems really negative. And what a cognitive therapist will do is literally get you to write down those thoughts and then re evaluate those thoughts, looking at the hard evidence. for and against those particular thoughts. So it's like a very specific type of therapy where you sit with your cognitive therapist, you write your thoughts down and you'll learn this technique for looking at the thoughts and saying, if you're using in the jargon, if you're using any errors of thinking, so it might be you're using the error of generalization. Where everything seems negative, and because one thing's gone wrong, everything seems wrong. And your Cognitive Therapist will help you work on those thoughts. So separately and distinctly, there's Behaviour Therapy, so that's the B out of the CBT. And that's not focused on the thinking. It's focused on what you actually do. So a good example of that is actually behavior therapy for anxiety disorders, where you use what we refer to as exposure therapy or desensitization, where you set tasks for the patient, physical tasks, and say If they've got an anxiety disorder related to going on buses, you'll set tasks, like the first task might be to go and sit at the bus stop for 40 minutes, and the final task in a series of 8 gradually increasing tasks might be to get on the bus and go for 10 stops on the bus. You've got cognitive therapy looking at the thoughts. In your head that drive the illness and behavior therapy, which is focusing on what you actually do and setting tasks for the patient to do based around behavior. Okay, so with a combination of the medications and using these various therapy techniques most people would improve. And then there'll be occasional ones that might need to come and see you for an opinion,? Dr James Hundertmark: That's right. So Usually we'll be seeing a patient who has failed One or two or perhaps three trials of different antidepressants. They might have seen a psychologist or even two and not responded. And then they come along to us to try and tailor a more specific and perhaps slightly more powerful treatment program. and how would you address the treatment then for patients that require further help?

Dr James Hundertmark: 23:43

So The starting point would be to just review the diagnosis. So occasionally you'll review the diagnosis and you might decide that it's not a true biological depression and that because it's not a true biological depression it's never going to respond to an antidepressant medication. more commonly it is a severe biological depression, and we'll then be thinking about the range of treatments. So we'll be thinking about adding to the medications to get a combination of medications that might work, but we will also be thinking about what sort of psychotherapy we think might help that particular patient.

Dr Gavin Nimon: 24:31

Excellent. And then obviously you mentioned previously in the more severe cases that have a psychosis attached to it, they're the patients that may require further ECT, and I presume that's something also that you may offer in that scenario.

Dr James Hundertmark: 24:45

and so with a psychotic depression and sometimes even with a non psychotic depression, one of the things that we'll commonly do Particularly in private psychiatry is the patient will usually already be on an antidepressant medication. These days it's also quite common to use two antidepressants at the same time. If I look back... Twenty years ago, um, I was certainly a single antidepressant purist. I would never mix antidepressant medications. But now we do that a lot more commonly. And, for example, a common combination of medications is to use one antidepressant in the morning, that's activating, and one antidepressant at night, at the same time, that's a bit sedating. And, for example, a very common combination of antidepressants now is the combination of venlafaxine, which is a serotonin and noradrenaline acting antidepressant, and we'd use that in the morning, and we'd combine that with metazapine, which is also a dual acting antidepressant. But it's sedating and you take it at night., It's common for us to use two antidepressants and if the patient's still not responding and it doesn't have to be a psychotic illness, we also do now use what we refer to as atypical anti psychotic medications. Just Put a bit more context on that. In the past, we had the standard anti psychotic medications, chlorpromazine, haloperidol, thyridazine, those sort of drugs. And say 20 years ago now, we had a whole bunch of new anti psychotic medications that acted in a slightly different way. Just to be a bit more specific for a sec, the traditional anti psychotics Tended to have a dopamine focused action, but the newer atypical antipsychotics also work on other neurotransmitter systems like serotonin and other things. And to come back to the point of a severe depressive illness, we might have a patient on three medications and to use those two I mentioned before, they'll be on the venlafaxine and the mirtazapine, and we might add. An atypical antipsychotic, specifically a drug like Olanzapine. And so Olanzapine is a drug that you could use for schizophrenia at a dose of 30 milligrams, but we might use it at 2. 5 milligrams or as little as 5 milligrams. And that particular drug really seems to help with a depressive illness. So I've sometimes seen patients who come to me from a GP They're really unwell, they're very agitated with their depression and you give them just a tiny bit of Olanzapine and it makes a world of difference and it helps really pick up that depressive illness and get them back on track.

Dr Gavin Nimon: 27:58

Right,

Dr James Hundertmark: 27:59

And so then if we're talking about a patient who has become psychotic with their depressive illness we probably already have them on an anti psychotic medication and it may be the case that they're still not responding. And it can be the case that it almost becomes urgent because the patient can be not eating and not drinking, and they might also have quite intense suicidal thinking. And oftentimes the best way to turn that around is to have a course of ECT.

Dr Gavin Nimon: 28:36

and that's electroconvulsive therapy,

Dr James Hundertmark: 28:38

Electroconvulsive therapy.

Dr Gavin Nimon: 28:41

and that involves a general anaesthetic,

Dr James Hundertmark: 28:44

Yeah, it's probably important to say that ECT is vastly different from how it was even when I started my training. So when I started my training in 1990, it was still a relatively crude operation if you like. We used to use a little Box with four dials on it so you'd be adjusting the voltage and the waveform and the current and the length of the shock that you gave to the patient. You'd have an anaesthetist with you. The patient would get a full general anaesthetic. They'd go right off to sleep. You'd apply the electrical stimulus and you'd physically watch the way the patient moved You'd watch the convulsion that they had and that would be your measure of how strong the ECT was, if you like. These days, the procedure is incredibly sophisticated. So patients have an EEG, so they've got a brainwave scan, all through the ECT. There's a stimulus dosing, what we call a stimulus dosing. So the amount of electricity is very slowly and gradually increased from a tiny amount up to exactly the amount that you need to cause a seizure. Because we know that a seizure is the curative issue with ECT. So you've got the anaesthetist there. You're gradually increasing the amount of stimulus. And you then have a series of ECT sessions which you need to make the patient remit.

Dr Gavin Nimon: 30:30

So obviously the thought that comes to mind is that, are there any side effects associated with E C T treatment?

Dr James Hundertmark: 30:35

Yep, there certainly are. It's like with any treatment in medicine, there are side effects. So obviously you're having a general anaesthetic. It's a very short general anaesthetic. So the, all the usual side effects with anaesthesia can be there. So sometimes patients will have a sore throat because they've been intubated., Sometimes patients will have headache because they've had tightness of the muscles as they're getting the ECT. One of the side effects that is often talked about , relates to memory. The usual kind of memory impairment from ECT is just loss of memory from the time that you're actually having the ECT. And when I'm describing this to patients, I often say it's if you were reading a novel throughout the couple of weeks where you had your ECT, you might lose memory of what you read in the novel the night before the ECT or on the morning after the ECT.

Dr Gavin Nimon: 31:37

That could be a side effect of the anesthesia itself, though could

Dr James Hundertmark: 31:39

Yeah, but the ECT often causes that mild, patchy memory loss. Very occasionally, and I've seen this once with one of my patients there's a term referred to as autobiographical memory loss. And so this gets into a loss of memory for events back over the person's lifetime. And I might also say I feel comfortable enough about ECT that I've let one of my own family members have ECT because I know it's a really effective treatment and people really get better quite quickly sometimes.

Dr Gavin Nimon: 32:17

presume, obviously there'd be muscle relaxant to stop any physical damage they would get with a major seizure.

Dr James Hundertmark: 32:23

Absolutely. And so if we go right back into the bad old days of psychiatry, and we're talking around the 50s and 60s patients had ECT without a muscle relaxant, and they do nasty injuries and so that's... That's the bad old days. So you have a full general anesthetic and a full muscle relaxant. And if you or I were standing there next to the patient having ECT, you'd only see a mild flickering of the hands and the feet. You don't see any other kind of seizure activity. And the way the, Strength of the seizure is judged now, it's on the EEG reading. So it's like on that brainwave reading, the psychiatrist looks at that to see is it a 30 second seizure, is it a 40 second seizure.

Dr Gavin Nimon: 33:20

So if we took across the whole board of people who suffer from depression,, the vast majority will respond well to medications, and then some will need psychotherapy, and only a few percentage will come to see you, and even then a smaller number will require ECT. What percentage, and for the listener and the layperson listening, not to worry them about having to go down this path, the number of people that require ECT will be very few I presume, is that correct?

Dr James Hundertmark: 33:44

It will be very few, . They'd see their GP, they'd respond to maybe the first antidepressant they're offered, and also they might do some quite useful counselling just with the GP. So it might just be a question of seeing the GP, talking about issues with the GP, go on one antidepressant and their episode of depression will respond.

Dr Gavin Nimon: 34:06

Now we talked about some of the medications being associated with depression. What about some of these medications we're using? The serotonin agonists causing side effects. And I know the antipsychotics in the past could have associations with Parkinson's

Dr James Hundertmark: 34:19

so the way it's evolved historically is for a long time we pretty much just had tricyclic antidepressant medications. so When I was a registrar to start with, all we had was tricyclic antidepressants and we would pick a tricyclic antidepressant through the range and specifically it was things like the cholinergic side effects And the one that was, had the strongest cholinergic side effects was amitriptyline. And you still see that drug around mainly in the chronic pain space. but so with those tricyclic antidepressants, we used to see a lot of side effects with constipation, dry mouth, blurred vision, postural hypertension, that sort of thing. and then the serotonin acting antidepressants, Prozac in particular, came onto the market. And the drug companies initially were saying, They've got none of the bad old side effects. These drugs are really good. But, in fact, like all drugs, they've got side effects. And the common ones are things like agitation. So some patients taking Prozac, or Zoloft, or any of the serotonin drugs, get really agitated. And a small percentage just get so agitated they can't tolerate those drugs, and they have to use another class. Gastrointestinal side effects are really common with the serotonin acting drugs. And the other one that kind of emerged at that stage was sexual dysfunction. So this is loss of libido, difficulty getting erections, and delayed ejaculation. And for women anorgasmia, and so that... Class of side effects emerged as an issue with the serotonin acting antidepressants. And since then, there've been a number of other classes that have come in. And some of those classes, for example, have a very low incidence of sexual dysfunction. So some of those other newer drugs are preferable if you've got a patient who's particularly concerned about sexual dysfunction..

Dr Gavin Nimon: 36:26

We talked before about the use of dopamine medications affect dopamine function, the Parkinson's medications also have any influence on either incidence or the reduced incidence of depression?

Dr James Hundertmark: 36:38

The issue with dopamine... In psychiatry, probably more relates to psychosis because we know that Parkinson's disease is about a deficiency of dopamine. And when we're trying to treat Parkinson's disease in medicine, we're trying to give drugs that increase the level of dopamine. Whereas with psychosis, the traditional model of psychosis was that there was too much dopamine and those original drugs for Treating psychosis would reduce dopamine. and that's where a heavy dose of anti psychotic medication would look like Parkinson's disease in some patients. Because you were really pushing down their level of dopamine and they'd start to have tremors and other symptoms, like what we know as mask like facies, which looked like Parkinson's disease. And the opposite is the case too, that A medication for Parkinson's disease can actually, in some patients, cause psychotic symptoms. So it's that dopamine dimension from being too little and being associated with Parkinson's or too much and being associated with psychosis.

Dr Gavin Nimon: 37:55

So we've got the serotonins or pathway for depression. There's a dopamine pathway with psychosis and Parkinson's. Where does the noradrenaline medication come into it then?

Dr James Hundertmark: 38:05

Yeah, the noradrenaline hypothesis was another hypothesis in the treatment of depression. So that was a hypothesis from the 60s where they felt noradrenaline was important in that , in treating depression and those, tricyclic antidepressants, and a couple of the other more modern classes work on the neuroadrenaline system., Personally, my own view is that we really know very little about neurotransmitter function and we're still in our early days of understanding the brain and the brain's incredibly complicated and there are millions of neurons and there are multiple different neurotransmitters and it's just Incredibly complex and sometimes people will say, Do you think there'll be a time where psychiatry will be dead and you'll all be neurologists? And to that I would say no. I think the brain is so complicated that there's always going to be a space for us in psychiatry because we're sitting there. between science and art, if you like. It's a mixture of the two things. And I don't think we'll ever be able to say, um, this is Gavin, this is his brain, this is how his brain works. We'll give him exactly this drug and we know it'll fix this issue. I don't think we're ever going to get there.

Dr Gavin Nimon: 39:33

Yeah. On that point, I was going to ask about the other things like Autism Spectrum Disorder or Personality Disorders? Are they associated with depression or anxiety

Dr James Hundertmark: 39:44

certainly if we take personality disorders... And in particular, if we take the condition known as Borderline Personality Disorder, that is a condition that has a very strong mood, or we use the term affective. There's a very strong affective component, and people talk about borderline patients as having affective instability. They really struggle to regulate their mood and what you tend to see is it's Almost like a type of bipolar disorder, but the shifts in mood are really rapid and could happen 10 times within a day. so At one moment they might feel angry, another moment they might feel sad then they might feel really deliriously happy. And for borderline patients, we're inclined to think they actually have trouble Identifying what their moods are sometimes they get confused, like they feel themselves really full of emotion, but they can't identify what that emotion really is. And one of the things that people probably know about with Borderline Personality Disorder is one of the core issues for them is they get a lot of suicidal thinking, they have a lot of thoughts of deliberate self harm, so they get trapped into this strange way of dealing with their mood.

Dr Gavin Nimon: 41:13

There's another area altogether, and another topic for a podcast another time. What about, with autism podcast I thought I'd read somewhere there was some association as well,. Dr James Hundertmark: Certainly the moment is There's an explosion of diagnosis in the area of autism, and there's also a huge amount of diagnosis happening in the area of ADHD. And those two conditions are taking up a huge amount of time as far as referrals to psychiatrists, and treatment in particular for ADHD. And both of those things are just So much more common now than they were 15 20 years ago, that we have to almost sit back and have a rethink and try and understand what's happening in the world now that makes autism and ADHD so much more common. And one of the differences now is that 20 years ago, people would come to the psychiatrist would do a diagnostic interview, and they'd say, I think you're having a major depressive disorder. Now, the patient comes and they say to you, I've got autism, or they say, I've got ADHD. I've been online. I've done some surveys. I know I've got ADHD. Can you treat it for me? And it's It's turned on its head from how it used to be. And right now, people with ADHD will tell you they can't find a psychiatrist, because the demand is just so huge at the moment. And, I really, personally, I can't explain why that's happened, but it's it's just very common at the moment. So do you think there's any association though with depression on that side of things? Dr James Hundertmark: I don't think so. I don't think so.. Dr Gavin Nimon: Now, moving on, holds for treatment of this? Do you think there's much on the horizon that looks promising for further treatment and new types of drugs or is it still a evolving specialty that we're still trying to get to grips with it all?

Dr James Hundertmark: 43:17

I think one of the important things is the way people get in touch with services is changing. And you might broadly use the term mental health literacy. I think people in the general community are becoming more and more familiar with mental health issues. They know that depression and anxiety are common. And I'm hoping that there's less and less stigma there, so that people feel more and more comfortable to go along to their GP and talk about it. And one of the other things that's becoming really common is internet based treatment. So to give you an example, there's a website and... So what I can do with patients now is I can see them for the first time, I can go to This and I can enroll that patient and they'll get a message come in to their email address. And I can also make it so that they don't have to pay anything, and then they can do online treatment of their condition. And say if they've got a depressive illness, they can use the online pathway, and gradually click through. It's almost like a a set of slides online that they can do, and it's often a cognitive therapy approach that gets used. So instead of me trying to take them through a cognitive therapy program myself, instead of a psychologist having to do it, they can actually do a self paced internet approach to treating their depression with a cognitive therapy, which can be really helpful. And just to expand on that a little bit more, I've got a patient right at the moment who's using This way out and if they have a lot of symptoms on a particular day There's a little flag that comes up on my email inbox and I know that it's sensible to give that patient a call and have a chat and just see how they're faring. So that kind of internet based treatment is a new and emerging area.

Dr Gavin Nimon: 45:21

So it's an adjunct to support your management as well. Is it saying that people would use spontaneously on their own without having seen someone? You'd probably not recommend that I'll assume.

Dr James Hundertmark: 45:31

Yeah, I think that's a good point because for us, a lot of the time in mental health, the bottom line is safety and we want to know that the patient is safe. So we want to know that their conditions under decent control so that they can use an online approach and that there aren't still safety issues that we need to, we need to get across

Dr Gavin Nimon: 45:54

yeah. Excellent. And last thing of all, what about lifestyle change, for depression particularly? I've read that the natural endorphin release from doing exercise is also very good for you and takes your mind off. The worries of life is it a myth or is it a truth factor that you know, good health and, eating well and exercising regularly is a good thing for you? I know you and I both enjoy our music, so that's one thing that takes our mind off it. But what about general lifestyle and other factors?

Dr James Hundertmark: 46:27

I probably mentioned three things alcohol, exercise and diet. One of the really big issues in mental health is alcohol and other drugs, but in particular alcohol you tend to see with some people, and it's particularly men more than women, that when they're struggling with their mental health, they tend to drink more. I do some work in the Northern Territory. When I'm up there, I'm staggered sometimes at how much alcohol intake patients have and when their mental health deteriorates, it escalates. I'm often trying to get people to reduce their intake. I'm often talking about trying to have alcohol free days to start with and then gradually attempt to cut back. So it's really important to monitor your patient's alcohol intake. And certainly exercise is very important. And I'll sometimes say to patients, look, if you exercise for half an hour, three times a week, You'll do way better than other patients who are not doing any exercise. So exercise is very important., I have a lot of patients who tell me they go to the gym they exercise, but the other thing they do while they're there is they chat with people. And going to the gym becomes a social as well as a physical exercise activity, which is really helpful. And thirdly, as far as diet, just at the moment, there's an Australian psychiatrist who's really tuned in on the Mediterranean diet. And she argues that the Mediterranean diet in particular, so we're talking about olive oil tomatoes, all those things. That's eaten in that area of the world, but that's particularly useful for people with a mood disorder. So she thinks that's quite important for people.

Dr Gavin Nimon: 48:19

That's truly amazing. Look, there's so much more we could cover, so it's been brilliant speaking to you, James. Thank you very much.

Dr James Hundertmark: 48:27

Excellent. Thank you, Gavin. No worries.

Gavin NImon: 48:30

Thank you very much for listening to our podcast today. I'd like to remind you that the information provided is just general advice and may vary depending on the region in which you are practicing or being treated. If you have any concerns or questions about what we've discussed, you should seek advice from your General Practitioner. I'd like to thank you very much for listening to our podcast, and please subscribe to the podcast for the next episode. Until then, please stay safe.