In our Ask the Doctors series, we present you with some of the conversations we’re having with our own Science 37 doctors. Join us as we dive deeper into specific conditions and treatments through the lenses of physicians.
According to the World Health Organization (WHO), 350 million people worldwide suffer from depression, and it is the leading cause of ill health and disability. In this edition of Ask the Doctors, we sat down with Dr. Benjamin Furst, Science 37’s medical director of psychiatry and behavioral sciences, and Todd Adamson, Science 37’s associate medical director of psychiatry and behavioral sciences, to talk about depression and the myriad approaches to treatment.
Q: What are the current accepted treatments for depression? Is it simply therapy and medication? Is there anything else?
Ben: It depends who you ask. Those don’t represent all the treatments out there — there’s research on exercise and things like that, but I don’t know that all doctors uniformly recommend those things. What insurance companies pay for still lands in the buckets of either therapy intervention or medication. Then there’s the other side of it — what are people able to fit into their lives. Some people just do not have the time. It’s not to say medication is always the right thing, but sometimes that is what is possible, especially if you work a job and you can’t get off work. Even if what would benefit you most is having an hour or 45 minutes of therapy a week, and you can’t make that work, then people are sometimes funneled into the medication bucket.
Todd: Also, we’re viewing it through the lens of our Western eyes. The cultural component is important to take into consideration, and the whole notion of psychotherapy and psychiatry is a very Western thing. In other parts of the world, they would laugh. But that said, it’s also spreading to other parts of the world.
Q: When people think about psychotherapy, they think about sitting on a couch and talking about their feelings. But now we have started to hear about cognitive behavioral therapy (CBT). Is that the same thing, or are they different?
Todd: Psychotherapy is like an umbrella term, it’s a catch-all. In the last 60 years, CBT has come on board, after the early 20th century’s approach to psychoanalysis, which is the stereotypical lie-on-the-couch, Freud-type treatment. And then the model shifted after World War II to a more short-term focused model, the medical model, which we now know as psychiatry. Cognitive behavioral therapy focuses on the way we think and our behaviors. It’s a more present-focused, action-oriented, collaborative, working approach. It also incorporates more of the Eastern practices of meditation and mindfulness.
Ben: There are hundreds of therapies if you were to look. There’s probably a handful that are commonly used, and then you have other approaches like Primal Scream Therapy.
Todd: Yeah, you could come up with one this afternoon and call it S37 Psychotherapy. Psychotherapy is like the Mississippi river, and then there’s all these tributaries that run off of it.
Q: In other therapeutic areas, like cancer, there’s personalized medicine. Do you think something like that could work in the depression space? Could we tailor medication to particular people and particular symptoms?
Ben: I think we already — to some extent — offer personalized medicine at a gross level. You have to consider the features of someone’s depression. For example, if their depression involves significant low energy, then you might prescribe a medication that, although it may not be the primary effect of the medicine, maybe gives energy or stimulates. You’re tailoring medication choices all the time to help address existing problems. That’s where we are now. Most physicians, in general, are trying to do that as opposed to just looking at an algorithm. Step one is you start an antidepressant — Prozac, Paxil, Zoloft, Celexa — and within that group you can make some decisions that might result in better adherence, or better tolerability, or avoid certain side effects, from weight gain to sexual side effects, there are many things you can do. And if it’s a problem with a certain genetic type, is it possible that a certain medication would correct that? I think in some ways we’re headed in that direction, but I think it’s quite a way off.
Todd: And that’s the thing, I think, both in psychiatry and psychology, we have many different ways of helping it get more personalized. And this is where psychiatry and psychotherapy are different from other forms of medical practice, because they are more dynamic when you consider all of the possible causing factors. Depression can be tied to genetics, but it also could be related to a death, or work. I see many people in my practice because of work stress. Money problems, family stuff, all of these factors are going to be a little different. I could use a cognitive behavioral approach, but within that frame, I’m going to be doing little things differently here and there for the individual. And they may also be taking an antidepressant at the same time. It’s very dynamic and constantly evolving.
Q: How do you feel about using technology or digital medicine to treat depression?
Ben: We sometimes make the biggest impact on conditions or problems from observations we make in a larger environment. For example, epidemiologists are often very good at figuring out how a disease is transmitted because they notice where the wells are located, and they figure out that there are mosquitoes by the wells, and that creates this transmission of an infection. So looking at depression, the phone is a place where we can get this other picture that we’re not necessarily getting [from the person directly]. We can look at the way people use patterns, places people go, how often they’re socializing, the ways they’re socializing, how active they are, maybe the areas in which they are active…we can get additional information and possibly make more of an impact on someone’s life.
Q: There are apps specifically created to address depression. Have either of you used them, tried them out, recommended them?
Todd: The only one that I test drove a little bit was called MoodKit, and it uses CBT. But I use meditation apps and there’s breathing apps that I assign.
Q: So you incorporate some of the digital apps into treatment?
Todd: Yeah, depression, anxiety, and I use virtual reality exposure therapy in my treatment as well, for fears and phobias.
Ben: It’s not a sanctioned thing yet from a larger level — an app to treat something. You’d have to potentially get the FDA involved if you were to prescribe an app. There’s an app that FDA approved for substance abuse treatment not too long ago. I think that’s where we’re potentially headed. And I think doctors would be thrilled to have another tool — I know as prescriber, I would love to have other tools than just the medication that brings with it a bunch of side effects, or risks, or problems. If you can find something that would complement some other treatment approaches, that would be a great space, a gap to fill in terms of what we’re trying to offer people.
Q: Where do you think telemedicine fits into this?
Todd: Well, I think the reasons why we’re all doing it — bringing the care to the patient — is due to the many people who are challenged to get out and go to an actual office to see someone, just due to where they live or their job. You would have to balance it out, but definitely in early-stage treatment, telemedicine would be a great way of reaching people that would otherwise not be seeing anyone or taking any steps to treat their depression.
Ben: Also, there’s still stigma around mental health. Having the experience of working in a free-standing mental health clinic, sometimes it’s hard just for someone to get through those doors. So telemedicine helps in that you can reach somebody in different environments that would be easier for them. But telemedicine could be helpful even when you think about accessing specialty care in a primary care clinic — it’s more acceptable to go to the doctor for [physical] health complaints. Sometimes even depressive symptoms present as body complaints — pain, headaches, stomach aches, neurological symptoms, fatigue. And you can use telemedicine to interact with a consultant. Most mental health conditions, like depression, aren’t treated in a psychiatrist’s office. They’re treated in a primary care office. Just in terms of the numbers of people that are out there, psychiatrists are usually seeing people where their condition is a little more complicated or a little less treatment responsive, a little more chronic, things like that. So it’s a different population. The people I see most of the time, depending on the condition, have agreed to be in treatment. There’s already been acceptance. But there’s a whole population of people out there who aren’t going to come see me, and that’s where telemedicine would be helpful. In reaching that population that needs help, maybe before they get to the point of having a more chronic problem.
Stay tuned for more with Ben and Todd, as well as our other doctors! Do you have a question for a doctor that you want answered? You can comment on this post, or find us on Twitter and Facebook, but don’t forget to add #AsktheDoctors and tag us!