Oct. 15, 2023
Exploring the Realm of Mental Health: Understanding Depression and Treatment Options
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In an interview with Dr Gavin Nimon (Orthopaedic Surgeon), Adelaide Psychiatrist Dr James Hundertmark outlines depression delving into the intricacies of the DSM-5 system, the diagnostic tool used for mental health conditions in Australia. Our conversation with James demystifies major depressive disorder, melancholic depression, and adjustment disorders, coupled with an exploration of their effect on social interactions and overall quality of life. But we don't just stop at the diagnosis. We journey through the spectrum of treatment options, from cognitive and behavior therapies to more advanced treatments for severe depression. We also touch on the role of psychologists, GP mental health care plans, and the impacts of medications on patients.
Our discussions take a historical turn as we examine the evolution of ECT and we navigate through various medications associated with depression and their effects. Finally, we step into the ever-evolving landscape of mental health as we discuss the the changing ways people access mental health services, and potential new treatments. Concluding on a hopeful note, we also emphasize lifestyle changes, such as regular exercise and a healthy diet, as an integral part of improving mental health. Get ready for an insightful, in-depth exploration of the mental health sphere in Australia.
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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.
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These conditions are saying that all medical professionals should be aware of.
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Today we discuss depression and anxiety within Australia with Psychiatrists.
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James Hundertmark.
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James is a Private Psychiatrist working at Ramsey clinic in Adelaide.
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He Trained at the Repatriation hospital in South Australia.
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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.
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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.
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Join us as we speak to James about this critical aspect of Australian public health.
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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.
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I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and I'm broadcasting from Gardaland.
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I'd like to remind you that this podcast podcast players and is also available as a video version on YouTube.
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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.
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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.
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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.
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Therefore, you should always seek advice from your health professionals in the area in which you live.
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Also, if you have any concerns about the information raised today.
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Please speak to your GP or seek assistance for help organizations such as Lifeline in Australia.
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Well it's my pleasure now to introduce Dr.
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James Hundertmark.
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He's going to talk to us about depression and anxiety and the issue that occurs in Australia.
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Welcome, James.
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Hi Gavin, good to see you today.
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Well, thank you very much for coming on Aussie Med Ed.
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It's great to have you on board.
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And I'm looking forward to hearing about this really important topic.
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Perhaps we can start off, first of all, talking about how important depression and anxiety is in Australia.
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They are two separate conditions but it's often the case that people with depression have anxiety symptoms.
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So with a significant depressive illness, it's about 70 percent of people who also have comorbid anxiety.
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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.
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So we've got a number of conditions coming under the depressive spectrum and a number of conditions under the anxiety banner.
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And how do you actually classify these conditions?
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If we wanted to go strictly by the classification system, in Australia we use the DSM.
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The current version is actually called the DSM five tr, so that's the latest version of the DSM five.
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The TR stands for text revision and the DSM system is almost like a cookbook method for diagnosing mental health conditions.
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So it will list off the specific features.
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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.
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So it's pretty specific in that you need to have so many of a list of symptoms to warrant the diagnosis.
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By and large, under the anxiety heading, it's a little bit simpler, and there are fewer features to...
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Warrant the diagnosis.
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So the anxiety heading has got Panic Disorder, Generalized Anxiety Disorder just a straight Anxiety Disorder.
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And also the simple phobias come under that heading too.
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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.
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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
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so I might just start by saying we view anxiety and depression as what we call high prevalence disorders.
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And that means that they're very common in the community.
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So anxiety, depression get into that range of one in five.
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So they're really common in the community up to 20%.
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And when it comes to depression itself.
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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.
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in response to a particular stressor.
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These days under the DSM system, we don't strictly classify endogenous and reactive.
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It's more what we call a major depressive disorder and that's pretty much like the old fashioned endogenous depression.
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Or what we might call now a biological depression.
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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.
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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.
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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.
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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.
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So it's those symptoms that indicate you've got a biological depression.
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And within the DSM 5, there's also...
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A category of what we call melancholic depression, which is an even more severe biological depression.
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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.
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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.
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So if you like that reactive depression diagnosis lives on in the DSM 5 under the term adjustment disorder with depressed mood.
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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.
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So you can have this unspecified depressive disorder if the symptoms don't meet.
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the criteria for a major depressive disorder.
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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.
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And, by and large, a depressed phase of a bipolar disorder is a much more severe depression than major depressive disorder.
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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.
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So there are a few categories there underneath the heading of depressive disorders in the DSM..
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Honestly, classification in psychiatry is always a little bit arbitrary.
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But, for whatever reason, we've come to use this American system, the DSM system.
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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.
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You're going to have relapses and remissions where you get back to the baseline.
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And also for that kind of condition, we're much more wedded to thinking that antidepressant medication will help that patient.
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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.
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right.
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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.
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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.
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And this will commonly be things like people feeling that there's something physically wrong with them.
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People will feel very guilty, like pathologically guilty.
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Sometimes people will feel dirty and like they can't get themselves clean.
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So it's where your thinking starts to fail, if you like, and head into psychotic territory.
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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.
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And for patients who've got really severe depression, that's becoming psychotic.
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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.
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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.
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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.
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Is there any associations with some medications that can lead to a depression type symptoms as well?
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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.
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Where they'll really become really quite unwell.
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Be up all night, having all sorts of strange ideas, get very paranoid.
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And that's often caused by large doses of steroid medications.
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Maybe for rheumatological diseases or renal issues.
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All sorts of general medical things.
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Okay, what about the illicit drugs?
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Do they have an association with depression as well?
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Yeah they certainly do.
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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.
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That the chronic use of marijuana, as well as causing what we refer to as an amotivational syndrome, also worsens anxiety and depression.
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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.
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And there's one group that don't have a vulnerability to psychosis and one group that do.
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And for those people who do have the vulnerability, if they use cannabis, they'll get psychotic.
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And for some of those people, they'll develop schizophrenia and they'll never recover from that condition.
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So that's a pretty clear bit of understanding that we've got about cannabis and psychosis now.
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Right that become a depression type of psychosis or is it just generalised schizophrenia
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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.
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It really flags that, for some people, cannabis use is really bad, and causes really bad psychiatric outcomes.
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What's the general sort of route that people tend to take when they suffer depression and for the average person you might see?
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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.
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So sometimes the patient will come and say, That they're feeling flat and sad.
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Sometimes it might be in response to a particular stressor.
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A common thing is relationship issues or relationship breakdowns would take people along to the GP.
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It's also worth saying that sometimes people can present on a number of occasions with physical symptoms.
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They might have.
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back pain, or they might have other sorts of physical symptoms, and they don't actually report depressive symptoms at all.
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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.
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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.
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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.
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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.
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So it's important to do those baseline screens.
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Usually they'll come back normal, but it's important to do them, and then you'd get on into treatment.
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And certainly if the flavour of the depression was more like a major depressive illness, GPs would be starting an antidepressant medication.
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And the commonest ones these days are those serotonin acting antidepressants.
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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.
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Originally we started out with the drug Prozac quite some years ago, which was very popular and very widely known in the community.
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And now we're on to the sixth iteration of those serotonin acting antidepressants.
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Now I believe there's also can be some issues with those serotonin and antidepressants as well with some drug interactions.
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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?
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Exactly right.
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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.
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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.
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So moving on from the GP using medications, are there other modalities you might use with someone suffering from depression as well?
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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.
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Psychologists are trained and certified to various levels.
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So You could do a three year degree in psychology and practice as a psychologist.
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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.
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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.
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And normally for someone who's got a significant mental health condition . I think it's important to use a clinical psychologist
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And what would that involve then?
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...
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Dr James Hundertmark: Usually, GP mental 10 sessions and then patients might get a second mental health care plan.
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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.
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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.
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You might get reassurance.
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So that's the first type of supportive psychotherapy.
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Then there's this expression a lot of people use now, . And what that stands for is Cognitive Behavioral Therapy.
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But really I like to split the C from the B.
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And so you've got Cognitive Therapy, which is focusing on the thoughts that you have in your mind.
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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.
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And they make you see the world around you as very negative.
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You feel very negative in that world.
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And when you look ahead to the future, it seems really negative.
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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.
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for and against those particular thoughts.
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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.
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Where everything seems negative, and because one thing's gone wrong, everything seems wrong.
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And your Cognitive Therapist will help you work on those thoughts.
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So separately and distinctly, there's Behaviour Therapy, so that's the B out of the CBT.
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And that's not focused on the thinking.
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It's focused on what you actually do.
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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.
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You've got cognitive therapy looking at the thoughts.
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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.
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Okay, so with a combination of the medications and using these various therapy techniques most people would improve.
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And then there'll be occasional ones that might need to come and see you for an opinion,?
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Dr James Hundertmark: That's right.
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So Usually we'll be seeing a patient who has failed One or two or perhaps three trials of different antidepressants.
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They might have seen a psychologist or even two and not responded.
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And then they come along to us to try and tailor a more specific and perhaps slightly more powerful treatment program.
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and how would you address the treatment then for patients that require further help?
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So The starting point would be to just review the diagnosis.
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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.
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more commonly it is a severe biological depression, and we'll then be thinking about the range of treatments.
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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.
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Excellent.
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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.
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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.
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These days it's also quite common to use two antidepressants at the same time.
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If I look back...
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Twenty years ago, um, I was certainly a single antidepressant purist.
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I would never mix antidepressant medications.
00:24:50.309 --> 00:24:52.589
But now we do that a lot more commonly.
00:24:53.200 --> 00:25:07.539
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.
00:25:08.390 --> 00:25:28.309
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.
00:25:28.769 --> 00:25:47.539
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.
00:25:48.529 --> 00:25:51.250
Just Put a bit more context on that.
00:25:51.920 --> 00:26:01.769
In the past, we had the standard anti psychotic medications, chlorpromazine, haloperidol, thyridazine, those sort of drugs.
00:26:02.460 --> 00:26:12.750
And say 20 years ago now, we had a whole bunch of new anti psychotic medications that acted in a slightly different way.
00:26:13.130 --> 00:26:31.464
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.
00:26:32.065 --> 00:26:46.914
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.
00:26:47.849 --> 00:26:53.900
An atypical antipsychotic, specifically a drug like Olanzapine.
00:26:53.900 --> 00:27:02.329
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.
00:27:02.390 --> 00:27:05.680
5 milligrams or as little as 5 milligrams.
00:27:06.200 --> 00:27:10.720
And that particular drug really seems to help with a depressive illness.
00:27:11.440 --> 00:27:29.059
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.
00:27:30.019 --> 00:27:30.589
Right,
00:27:31.150 --> 00:27:45.859
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.
00:27:47.980 --> 00:28:00.329
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.
00:28:01.250 --> 00:28:06.539
And oftentimes the best way to turn that around is to have a course of ECT.
00:28:07.700 --> 00:28:09.869
and that's electroconvulsive therapy,
00:28:10.089 --> 00:28:11.759
Electroconvulsive therapy.
00:28:12.769 --> 00:28:15.490
and that involves a general anaesthetic,
00:28:15.509 --> 00:28:24.460
Yeah, it's probably important to say that ECT is vastly different from how it was even when I started my training.
00:28:24.980 --> 00:28:33.099
So when I started my training in 1990, it was still a relatively crude operation if you like.
00:28:33.500 --> 00:28:47.884
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.
00:28:48.414 --> 00:28:50.214
You'd have an anaesthetist with you.
00:28:50.575 --> 00:28:52.795
The patient would get a full general anaesthetic.
00:28:52.964 --> 00:28:54.265
They'd go right off to sleep.
00:28:54.644 --> 00:29:09.355
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.
00:29:10.585 --> 00:29:16.144
These days, the procedure is incredibly sophisticated.
00:29:17.424 --> 00:29:23.295
So patients have an EEG, so they've got a brainwave scan, all through the ECT.
00:29:23.954 --> 00:29:28.025
There's a stimulus dosing, what we call a stimulus dosing.
00:29:28.545 --> 00:29:39.464
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.
00:29:39.884 --> 00:29:44.015
Because we know that a seizure is the curative issue with ECT.
00:29:45.075 --> 00:29:47.184
So you've got the anaesthetist there.
00:29:47.285 --> 00:29:50.545
You're gradually increasing the amount of stimulus.
00:29:51.674 --> 00:29:59.825
And you then have a series of ECT sessions which you need to make the patient remit.
00:30:02.200 --> 00:30:06.880
So obviously the thought that comes to mind is that, are there any side effects associated with E C T treatment?
00:30:07.430 --> 00:30:08.630
Yep, there certainly are.
00:30:08.650 --> 00:30:11.319
It's like with any treatment in medicine, there are side effects.
00:30:12.259 --> 00:30:14.410
So obviously you're having a general anaesthetic.
00:30:14.440 --> 00:30:16.710
It's a very short general anaesthetic.
00:30:17.059 --> 00:30:20.730
So the, all the usual side effects with anaesthesia can be there.
00:30:21.160 --> 00:30:34.900
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.
00:30:35.359 --> 00:30:40.539
One of the side effects that is often talked about , relates to memory.
00:30:40.539 --> 00:30:49.299
The usual kind of memory impairment from ECT is just loss of memory from the time that you're actually having the ECT.
00:30:50.890 --> 00:31:07.130
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.
00:31:08.650 --> 00:31:11.224
That could be a side effect of the anesthesia itself, though could
00:31:11.240 --> 00:31:16.849
Yeah, but the ECT often causes that mild, patchy memory loss.
00:31:17.700 --> 00:31:27.130
Very occasionally, and I've seen this once with one of my patients there's a term referred to as autobiographical memory loss.
00:31:27.670 --> 00:31:34.089
And so this gets into a loss of memory for events back over the person's lifetime.
00:31:34.700 --> 00:31:48.059
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.
00:31:48.960 --> 00:31:54.480
presume, obviously there'd be muscle relaxant to stop any physical damage they would get with a major seizure.
00:31:54.704 --> 00:31:55.535
Absolutely.
00:31:55.914 --> 00:32:15.005
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...
00:32:15.325 --> 00:32:17.164
That's the bad old days.
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