Depression, or Major Depressive disorder (MDD), is a common mental health disorder in the USA. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 7.1% of all US adults, or 17.3 million people, had an episode of depression in 2017. The prevalence of depression was higher among females and highest in individuals between 18-25 years old.
Given that May is mental health month, I wanted to talk about depression. As a pain physician, many of my patients battle depression and anxiety in addition to their chronic pain. Many patients have posttraumatic stress disorder (PTSD), sadly due to traumatic childhood events or poor relationships as adults. It is exceedingly difficult to treat these patients, as they have been through medical management, nerve blocks, physical therapy, acupuncture…and the list goes on.
I’m a huge advocate for cognitive behavioral therapy and those seeking help with their mental health. To me, these patients actually are trying to get better. In my clinical experience, when my patient takes an active role in their health, they do ultimately improve. Sure, they may need some guidance, but the ones that seek treatment for major depressive disorder or PTSD show improved functionality and improved (lower) pain scores at follow up visits.
So, how is depression, or major depressive disorder, diagnosed? Depression is characterized by having one or more major depressive episodes for at least 2 consecutive weeks. A major depressive disorder consists of five or more of the following symptoms, nearly every day:
- Depressed mood for most of the day
- Inability to sleep or sleeping too much
- Losing interest in activities that normally bring enjoyment
- Fatigue or low energy
- Difficulty making decisions, focusing, or concentrating
- Feeling worthless or excessive guilt
- Significant weight loss or weight gain due to an increase or decrease in caloric intake
- Agitation that is noticed by friends and family
- Suicidal thoughts
Do most people go through bouts of any of the above symptoms? With the exception of #9, definitely. And, if anyone is actively suicidal, please go to the local ED as soon as possible.
Will labs show depression? It depends. When I see a patient who tells me they are depressed, but it is not in their medical history, I check labs. I order a complete blood count (CBC), complete metabolic panel, urinalysis, thyroid studies, and a tox screen. Sometimes, an undiagnosed medical condition like hypothyroidism or anemia due to a variety of things can present as fatigue and depression. Maybe they were exposed to radiation or heavy metals. Many medications, like beta blockers, steroids, or statins can cause depression. Conditions like hypothyroidism and anemia are treatable, and once treated, patients feel better and have more pep.
The challenge is when all the labs are normal. Once underlying medical conditions have been ruled out, and labs are normal, what is the next step? Medications are an option, as is psychotherapy. Randomized controlled trials have shown that a combination of psychotherapy and pharmacotherapy is more effective than either treatment alone.
There are a variety of medication classes for depression. Selective serotonin reuptake inhibitors, or SSRI’s, are commonly prescribed for the treatment of depression. Examples of SSRI’s are Prozac, Paxil, Zoloft, Lexapro, and Celexa. Tricyclic antidepressants, or TCA’s, such as amitriptyline, nortriptyline, and imipramine are also utilized. Serotonin Norepinephrine Reuptake inhibitors, or SNRI’s, such as Effexor, Cymbalta, and Pristiq are examples. Interestingly, SSRI’s do not improve pain, whereas TCA’s and SNRI’s have shown benefit in chronic pain.
Like any medication, there is the potential of side effects of antidepressants. Diarrhea, nausea and vomiting, increased fatigue and somnolence are common side effects. More significant side effects include sexual dysfunction and weight gain. Excessive blood thinning, as supported by retrospective studies showing hemorrhagic strokes in patients, can be catastrophic.
Are there alternatives to daily medications and psychotherapy, or things we can do to improve mood and get us out of a rut? Yes, definitely. If a patient is already seeing a psychiatrist or in a program, the following are not meant to replace what they are doing, but can be used in conjunction.
Exercise has been shown to be beneficial for heart disease, obesity, diabetes, and cancer prevention. Exercise has also been associated with improved cognitive function, and has been shown to improve sleep, reduce stress and anxiety, and lower depression.
Sleep is when our cells regenerate, and people who have poor sleep hygiene have a higher incidence of mental health issues. According to the Centers for Disease Control and Prevention, adults aged 18-64 need at least 7 hours of sleep a night.
Multiple review articles have shown that yoga reduces anxiety and stress.
Numerous clinical trial have shown that Tai Chi, or Qiqong exercises decrease depression and anxiety.
Ketamine is an anesthetic drug that has sedative and analgesic (pain alleviating) properties. There are over 50 academic papers that have shown that ketamine can improve symptoms of depression, including treatment resistant depression. It has also been shown to be helpful in patients who have suicidal ideations and PTSD. Ketamine is a controlled medication, and should be administered under the vigilant eye of an anesthesiologist, who has the training to manage any potential side effects of the drug for patient safety. At RevIVe Wellness, we infuse subanesthetic doses of ketamine based on body mass, via intravenous infusion over an hour.
I have infused ketamine in patients with chronic pain, specifically those with neuropathic (nerve) pain. I noticed that whereas some patients responded very well with ketamine, some patients did not get the pain relief they were seeking; however, their moods seemed to improve which would indirectly improve their pain.
Regardless of treatment, it is important that individuals get help if it’s needed. I’m glad that over the years, there are fewer stigmas and more support for those who actively seek treatment. Even though we are nearing the end of Mental Health Awareness month, we will continue to discuss the importance of mental health throughout the year.