Depression Symptoms and Treatment Strategies | Evidence Based Interventions

Hey there, everybody, and welcome to this presentation on treatment strategies for depressive disorders. I'm your host, Dr. Donnellice Snipes. In this video, we're going to explore current evidence based practices for the treatment of depressive disorders. Now, you may be asking, what are evidence based practices? These are interventions that have been studied, studied in the research and have shown positive effects for treating depression or depressive symptoms across multiple studies and across many, many, many people. It's not just a case study, it's not just a theory. These are things that have been shown to be effective with people. Why is this important? Well, unfortunately, the research also shows that less than 50% of people actually achieve full symptom remission with typical antidepressants or psychotherapy. Now, if you combine antidepressants and psychotherapy, we get up over the 60% mark, but not very far over the 60% mark, which means we've got 40% of the people who are still experiencing significant symptoms. This underscores the importance of recognizing depression as a biopsychosocial issue. When people are depressed, it affects them physically, it affects them emotionally, it affects them cognitively, it affects their relationships. And if we don't address all of the factors that are contributing to their depression or maintaining their depression, we're probably not going to help them achieve their highest quality of life. So let's start out with physical interventions and, and in graduate school, in counseling, we really don't talk about this enough, if at all. And the research is undeniable that people who get poor quality sleep, who get insufficient quality sleep, are at a much higher risk of developing mood disorders, including depression. So helping people look at their sleep hygiene, are they doing everything they can to ensure that they are getting sufficient quality sleep? And I've got several videos on the YouTube channel that talk about sleep hygiene and the importance of sleep and circadian rhythms for managing mood disorders and even preventing mood disorders. Some people may need a sleep study if they're not sure if they're getting quality sleep or they awaken and they don't feel refreshed ever. They may go to their doctor and be referred for a sleep study to see kind of what's going on when they're actually asleep. Another cause of poor sleep that just absolutely needs to be addressed is obstructive sleep apnea. Obstructive sleep apnea, or osa, is when people regularly stop breathing when they're asleep, and that wakes them up. Every time they stop breathing, they will like snort or gag or whatever word you want to use. If you've heard somebody with osa, you know what it sounds like because they are really loud snorers. But every time they stop breathing, they wake up a little bit and then they go back to sleep. They may not recognize, they may not realize that they're waking up, but they are, and that is disrupting their sleep significantly. One of the first interventions I use with people or I suggest to people is to get their sleep and their circadian rhythms and in sync. And each one of the hyperlinks throughout this presentation does take you to the studies in PubMed that describe exactly why this works or the studies that have been done that show it works. Another physical intervention for depression is pain management. When people are in pain, guess what? It impacts their sleep. But aside from that, when people are in pain, they can start to feel helpless and hopeless. They can feel frustrated because they're always in pain. There is a strong correlation between pain and depression, especially chronic pain. There's also a strong correlation between inflammation and pain and, and inflammation and depression. Helping people get their pain and inflammation under control is another essential aspect of physiological recovery. When people are depressed, as serotonin goes down, we see that their pain tolerance also goes down. So people who are depressed actually experience more pain as a result of their depression. Doesn't that suck? So we want to help them figure out what they can do to mitigate that pain as much as possible. And there are a lot of non pharmacological interventions that can be used that can be very helpful, like massage and tens units and yoga and acupuncture. So it's important that they go see their doctor if they've got chronic pain. Cardiovascular disease is another issue that can contribute to depression in a lot of people. And this includes hypertension, copd, heart disease. Anything that affects the body's ability to transport oxygen around, to transport blood around, falls under that cardiovascular disease umbrella. And when the body is not fully and adequately oxygenated and nourished, it leads, it causes stress, causes the HPA axis to be triggered and contributes to feelings of fatigue and irritability and generally also negatively impacts sleep. Many people will not have cardiovascular disease and depression that you see, they may just present with depression. But if they do have cardiovascular disease, it's important that that is addressed. Hormones, testosterone, estrogen, progesterone, etc. All of those gonadal hormones and thyroid hormones, when those are out of whack, they contribute to mood issues. Too little often contributes to depression and too much often contributes to anxiety and anger. But it really depends on the hormone, any of these things can be addressed, can be noted in a annual physical. People can go to their doctor. And most insurance companies cover your annual physical. So going in for that annual physical as a preventative or a wellness check is generally doesn't cost people anything. And during that visit, the doctor will run blood panels, urine screens, et cetera, in order to make sure the person's body is functioning as well as possible. And during that wellness visit is a great time to talk with the doctor about sleep problems or pain problems. Nutrition is another aspect that is so important in recovery from depression. Now, as mental health clinicians, as social workers, we are not registered dietitians. We cannot prescribe a menu, we cannot prescribe a diet. We, we can educate people about the importance of good nutrition and about the impact of inflammatory foods. But if they need help designing a menu plan or figuring out what to eat, they definitely need to consult with their doctor or registered dietitian. That being said, there are a lot of studies that show the connection between poor nutrition and mood issues. Why is that? Remember, what we eat becomes the building blocks to make the hormones and the neurotransmitters and the tissues and everything else that our body needs to make in order to help us stay functioning. It's the raw materials. So if we put crappy raw materials in, then we may get crappy results out. So it is important to remember that. Now your neurotransmitters, for example, are made from amino acids from proteins that you eat. But you can't just eat proteins and expect your body to do it. The chemical reactions that break down the amino acids to make them into neurotransmitters also require the whole spectrum of vitamins and minerals, which is why you need to eat a good, well rounded diet. It doesn't have to be, you know, super duper, you know, health conscious, but, you know, reasonable. Anyhow. One of the studies that I looked at was a meta analysis of 11 other studies that contained a total of 101,950 participants. And it suggested that those on a pro inflammatory diet, which is what we typically think of as the American diet, have 140% increased likelihood. Let that sink in. 140% increased likelihood of being diagnosed with depression or displaying depressive symptoms. People who eat refined carbohydrates, white bread, simple sugars, those sorts of things, really highly processed foods, saturated fats, trans fats, lots of omega 6s, not many omega 3s, red meat and or processed meat like hot dogs and things that have nitrates and nitrites in them are eating what we call a pro inflammatory diet. All of these foods can contribute to inflammation. Now I have sugars. Start with a little asterisk here. Typically we think of sugars as sucrose. You know, your, your white sugar that goes into white bread, you may put in your coffee, those sorts of things. But it also includes other sugars like fructose. Fructose is your fruit sugar. And I'm going to talk in a minute about making sure to eat anti inflammatory foods. But, and a lot of your fruits are anti inflammatory in nature and when you eat them whole, you eat whole apples, cherries, peaches, nectarines, whatever it is that you want to eat. There is fiber that helps buffer the impact of the fructose. So eating actual whole fruits and vegetables helps the body acquire antioxidants which help reduce inflammation. And that, that fiber buffers the impact of the sugar so it's less inflammatory. It is important to eat a variety of colorful foods and vegetables. The darker the color, the more powerful it is at reducing inflammation. And, and so just kind of use that as a general rule when you're selecting vitamins or when you're selecting fruits and vegetables. Something like iceberg lettuce that's kind of a pale green, has a lot less antioxidant and anti inflammatory impact than something like spinach or kale or even romaine lettuce that is really dark in color. It is important because remember I said in order to break down the amino acids from their food form into something the body can use, you need the entire spectrum of vitamins and minerals. Your doctor, when they do your blood test, will be testing for iron deficiency, vitamin D deficiency, vitamin B12 deficiency, any of those deficiencies and can help you identify ways to remediate those. Interestingly, there are a lot of vitamin D receptors, the same area of the brain that is associated with mood. And that's one of the reasons that they started exploring the connection between vitamin D deficiency and depressive symptoms. The take home from this slide. Good nutrition is important. Lots of vegetables, a few fruits, and trying to avoid as much as possible red meat and processed meat, and minimizing your omega 6s again. I have several videos on the YouTube channel on nutrition for mental health that go into great detail about all of this stuff. Exercise. Now I know that's a bad word for a lot of people, but exercise just means moving your body, get up off the chair. It doesn't necessarily mean going the gym. Exercise and antidepressant medication may alleviate Depression through common mechanisms, including increased neurogenesis and expression of neurotrophic factors, increased availability of serotonin and norepinephrine, regulation of HPA axis activity, and reduced inflammatory signals. So let's go through each of those. Both exercise and antidepressants. You don't have to have them together, separate or together. Both interventions increase what they call neurogenesis. It increases the rate at which your body replaces neurons in your brain. And they found a significant correlation between a reduction in neurogenesis and an increase in depression. So when we increase neurogenesis, depression generally goes down. Obviously, your antidepressants are typically going to increase serotonin and norepinephrine, but interestingly, exercise does as well. And it doesn't have to be intense exercise in your target heart rate range or anything crazy like that. It can be just mild walking, cleaning the house, vigorously gardening, anything that moves your body that you enjoy doing. Exercise and antidepressants also both regulate HPA axis activity. They found that low intensity exercise, like a gentle walk, can actually reduce cortisol levels. And cortisol is your stress hormone, improve mood. So again, we're going back to, you don't have to kill yourself at the gym to get the benefits from exercise. And the part that I found most interesting was antidepressants reduce inflammatory signals, but so does exercise. Obviously, if you exercise too much, too hard, you're breaking down a lot of muscle tissue, you're going to have some inflammation and pain. But easy exercise often reduces inflammatory signals throughout the body, partly because it helps increase circulation, increase hydration, and get rid of some of that oxidative stress. It gets rid of some of the, the byproducts of your body's functioning every day. And those byproducts contribute to inflammation. So the faster we can get them out of the system, the less inflammation or less problems they can cause. And finally, and this is one of the newer interventions that I think is really interesting, vagus nerve stimulation has also been found to significantly impact mood. Your vagus nerve is mostly responsible for triggering the rest and digest response, as opposed to the fight or flee response. So the vagus nerve goes from top of your head all the way down through all your organs. It connects just about everything. And when the vagus nerve is not activated, if it's not activating enough, if it's being overruled by the fight or flight response, then people can feel a lot of anger, anxiety, and eventually, if that goes unchecked, depression. Vagus nerve stimulation, getting the body trained, if you will to more effectively activate that vagus nerve can help people buffer against stress so they don't have the long term impact or long term unchecked anxiety and stress that can lead to depression. Medications the physical aspect wouldn't be complete without discussing medications. Now medications are not for everybody and I'm not saying that everybody needs to be beyond them by all means. The research has indicated that antidepressants are only effective for about 40% of the population. However, for those who do want to explore pharmacological interventions, obviously antidepressants are your first line treatment. You have your SSRIs, these are selective serotonin reuptake inhibitors. You have your SNRIs, your selective norepinephrine reuptake inhibitors and your SNDRIs selective norepinephrine and dopamine reuptake inhibitors. What's your doctor will help you figure out which one is the best one for you to start out with. A take home point that I think is important for everybody to recognize though is when you alter one of these, whether it's serotonin, norepinephrine or dopamine, it actually does impact all the rest of them. But an SSRI is going to have less impact, less effect on norepinephrine and dopamine than an sndri. So it just depends on what the doctor thinks is the best scenario for you. Psilocybin, and some people call this mushrooms, has been shown to be effective for people with treatment resistant depression with two monitored doses. This is not taking it home. This is not continuous use. This is two in office monitored doses of psilocybin have been shown to produce lasting antidepressant effects in some people. Repetitive transcranial magnetic stimulation, or RTMS has also been shown to be extremely effective for people with treatment resistant depression. Now why do I keep saying treatment resistant depression? Because these tend to be second and third line options after antidepressants and psychotherapy have failed to help the person achieve full remission. However, repetitive transcranial magnetic stimulation is non invasive. They just put the electrodes on the head. It doesn't involve any sort of surgery or an implantation or anything like that. It is the newer, kinder, gentler version, if you will, of what we used to think of as electroconvulsive therapy. Now ECT still does exist, but RTMS has been shown to be really effective at helping people address their depression and it can be used as a first line treatment for somebody, for example, who doesn't want to take SSRI'S or medications for somebody who can't tolerate them for some reason. Pregnant women have also been studied for RTMS because during certain phases of pregnancy it is strongly not advised to, to be on psychotherapeutic medications. So that is something to consider if you've got somebody who can't tolerate or can't be on medication for some reason. RTMS can be a great adjunct to psychotherapy and I knew people weren't going to ask about it, so I put it here. Ketamine IVs may be useful for acute suicidality, but it's not been shown to be effective for long term antidepressant effects. So if somebody is severely acutely suicidal, Ketamine through the intravenous methods has been shown to significantly reduce suicidal ideation. But it is very short lived and it's very expensive and, and it's not something that people are going to want to continue to do continuously. So that's where we're at with ketamine right now. Affective interventions now this is getting more into our wheelhouse as clinicians. Optimism has been shown to improve mood. Go figure. And that kind of goes along with using dialectics, embracing the good with the bad, and cognitive restructuring. Seeing things, seeing the glass as half full instead of half empty. Helping people develop a more optimistic and empowered outlook has been shown to significantly reduce depressive symptoms. Well, it makes sense. One of the key features of depression for a lot of people is a sense of feeling helpless and hopeless. Optimism is the opposite of helplessness and hopelessness. Positive psychology Interventions and positive psychology is an entire field, if you will. But interventions like savoring gratitude, kindness, empathy, strengths, awareness and goal achievement have all been shown to be effective at addressing or helping to address depressive symptoms. Savoring is one of those that's kind of unique to positive psychology and it has to do with mindful awareness of the moment. Savoring the taste of something you're drinking, savoring the smell of the ocean air as you walk along the beach. Savoring the moment can improve people's mood partly because when they're savoring. When you savor something, it's something you like. When you are immersed in something pleasant, positive, something you like, it triggers the release of serotonin and GABA and dopamine and you know, those feel good chemicals. It's not going to make you feel great right away, but it is one technique that people can use to improve their mindfulness and identify some of the positive things in their life, in their environment. Gratitude. They found that people who keep a gratitude journal often have less depression because they recognize that some of the things in their life that are going right, they also recognize some of the things that suck, but they recognize that there are some things going right. So it starts balancing out that negative emotional salience in their brain. They start seeing the good and the bad. Kindness, kind of similar to gratitude, kind of similar to empathy. But random acts of kindness. Being kind to other people has actually been shown to reduce depression. When people get out of their own head and they empathize with others and they show them kindness, it's been shown to improve their mood. Strengths. Awareness is another positive psychology intervention that helps people who feel hopeless and helpless become more aware of what strengths do they have? What capacities do they have to help them deal with life on life's terms? This again, helps them feel safer, more empowered, less hopeless and helpless. And finally, goal achievement is obviously helping people learn to set small, achievable goals, which increases their sense of what we call self efficacy or personal power. They start realizing, hey, I can do this. A lot of times people set goals that are not really well stated, they're kind of vague, or they set them that are too big. My goal is to get my doctorate. Well, you haven't even started college yet. And then they decide along the way that something else comes up and they never achieve their doctorate. Well, if that was the only goal, then they may feel bad. They may feel like they're not able to achieve their goals. If they had set smaller goals, incremental goals, then they would have had a sense of accomplishment. For getting into college, for getting their aa, for graduating from undergrad. Those are all much shorter goals that can help people feel like, hey, when I set my mind to do something, I can do it. When you set a goal that's too far out, There are too many variables that don't even have to do with the person. There are too many variables that can intervene that can prevent them from achieving their goal. And a lot of times when we fail to achieve our goals, we blame ourselves instead of considering what were all the other things that contributed to me not doing that? Cognitive interventions. Cognitive behavioral therapy is still the gold standard for addressing depression. There is what they call third wave cbt, which encompasses dialectical behavior therapy and acceptance and commitment therapy. All of these have been shown to be very effective. Now, why might that be? Because when people are depressed, when they're having difficulty concentrating, when they're feeling hopeless and helpless, when they are in that dysphoric or unhappy mood state, Their brain notices and pays more attention and perceives things as more threatening or overwhelming than if they were in a better mood. And when they perceive things that way, they start thinking that everywhere I look, it seems like it's raining or it seems like the sky is falling, which contributes to feelings of hopelessness and helplessness. By changing their cognitions and becoming more aware of everything out there and identifying instead of identifying only with what they cannot control, Identifying what they can control provides a sense of hope and empowerment, which is the opposite of hopeless and helpless. When people feel more hopeful and empowered, it increases positive neurochemicals, it decreases cortisol, it decreases some of those stress chemicals. All of that will contribute to reductions in inflammation and improvements in mood. Cognitive control training is another intervention that can be used with any of these others, including cognitive behavioral therapy. But cognitive control training helps people learn to what I call tame their monkey mind. Cognitive control training encourages people to, for example, evaluate the positive. You know, turn and assess what else is going on. You're noticing the bad, but what else is going on. Forcing yourself to look at the big picture instead of having tunnel vision. Cognitive control training can encourage you to focus on what is in front of you and be more mindful. When we're more mindful, we, which I'm getting down to mindfulness. When we're more mindful, we're more aware of our vulnerabilities and our triggers in the environment. Vulnerabilities are things that make you more likely to respond with an extreme response to distress when it comes your way. When you're vulnerable, when you're tired, when you're sick, when you're malnourished, when you're in pain, you, you probably are more likely to react to something more strongly than if you, you would if you were feeling better, if you were feeling happier, content, not in pain, well rested. So mindfulness is an essential tool for helping to prevent those, well, mitigate those vulnerabilities. You notice, hey, I'm tired. What do I need to do in order to give myself a buffer so I don't bite somebody's head off today? Mindfulness also helps you become aware of the triggers in your environment, both for distress, but also for happiness. You can increase the happiness triggers, and then you can buffer against or eliminate the distress triggers. Mindfulness and cognitive control really go hand in hand. In some ways, it's an aspect of cognitive control training. One of the other aspects of cognitive control training is helping people address ruminations. And Linehan talks about distress tolerance but cognitive control helps people identify and recognize. I don't have to keep thinking about this. I can turn my attention and focus on something else which can be empowering to recognize that you don't have to continue to sit there and experience the pain. You can turn your attention to something else environmentally. And I was really thrilled to see the that there have been a lot of studies on the positive impact of aromatherapy in the environment. Aromatherapy can be used in a lot of different ways. It can be used to stimulate feelings of calm and relaxation, stimulate feelings of concentration or focus. Which aromas to use? In large part, my experience has been depends on the person. Not everybody is going to smell lavender and find it relaxing. So it is partly up to the person. The terpenes in the essential oils are what have the significant impact. And those terpenes, when we inhale them, they activate sensors in our nose and our pituitary gland that trigger the release of neurotransmitters. And that's kind of interesting to look at Again, I do have another video on the YouTube channel on aromatherapy if you're looking for a primer there. Another environmental intervention that I thought was really cool was music medicine, especially in people with anxious distress. And they differentiated between music therapy and music medicine by the way it was used. Music therapy is using music in order to accomplish a particular goal. Working with a therapist to use music to reduce heart rate, working with a therapist to use music to accomplish improve concentration. For example. Music medicine is used more like medicine is prescribed where people are encouraged to identify music that can help them feel better. What is it that you want to use? Listen to music that makes you happy. Listen to music that's energizing. Listen to music that's cathartic. Whatever the goal is, use that music periodically throughout the day to trigger that emotional response. They found that music medicine was more helpful in people with anxious distress as opposed to people who were melancholy or extremely sad. So that's an interesting thing. Color therapy was not studied. So I'm not recommending it as an evidence based intervention. But it's something I think we should keep our eye out for because we know that colors influence mood. So if I'm sitting in a room and all the walls are black or all the walls are this really depressing cold gray color, I'm going to feel differently than if I'm in a room where the walls are butter yellow or red or orange or something like that. So it is interesting. But again, that's not an evidence based practice at this point. In time. Light therapy, however, is an evidence based practice and this is using bright light. This is not just lights in a room, nor is it using just regular old broad spectrum daylight lights, although those can be helpful for people. Light therapy involves choosing broad spectrum daylight bulbs that are extremely intense. The higher, the further the distance between the light bulb and the person, the more the light waves spread out and the less impact it's going to have. Which is why the light boxes that generally sit on their desk or on their table are used as opposed to choosing overhead lights. However, light therapy is very effective in both seasonal and non seasonal depression. Thought that was fascinating. We've always talked about light therapy in terms of addressing seasonal affective disorder, but it has also been shown to be very effective in people with non seasonal depression. This underscores the influence of circadian rhythms in the development of even non seasonal depression. Light therapy, its main goal is to help set those circadian rhythms. You do not get vitamin D from light therapy, so the only thing it does is help set those circadian rhythms. Nature therapy is also being studied quite a bit more now, which I think is amazing. It's absolutely fabulous. I do have a video on forest bathing and feng shui that is on the YouTube channel that goes more in depth into it. But forest bathing is a term for nature therapy where people go out into nature, they go out into a park, they walk through a natural area. They found that as little as 10 minutes of sitting or walking in a diverse array of natural settings significantly and positively impacted defined psychological and physiological markers of mental well being. It actually reduced cortisol levels, reduced blood sugar levels and positively impacted A1C levels. They found that this can be a variety of things. It doesn't have to be a forest, it can be a park, it can be by a babbling brook. It can be any sort of natural environment where you're not in a building, where you're not in the middle of the city getting into that natural environment, even going to a nice wooded, natural looking park in the middle of New York would give you some benefits, maybe not all the benefits because you're still hearing the horns and smelling the smog. They found part of the effect of forest bathing is from the terpenes, the aromas that are exuded by a lot of the plants. But, but it's also partly due to being in an environment where there's more oxygen. Plants take in carbon dioxide, release oxygen, so you're in a more oxygen rich environment and you're separated from, theoretically separated from the hustle and bustle of daily life. You don't have, you know, phone calls ringing and all this other extraneous, distracting, stressful noise. Another type of nature therapy, which has been used extensively, both with adolescents as well as older adults and older adults with dementia, is horticulture therapy. And that's just what it sounds like. Growing stuff. It can be growing flowers, planting trees, growing vegetables, raised garden beds. Horticulture therapy can even be done with hydroponics. They speculate again that part of the benefit is the person feeling like they are able to interact and do something and produce a positive result. But also interacting with the plants and which are producing oxygen can also be very, very helpful. And relationally, I was sad that the research on animal assisted therapy is a very poor quality as of yet. Animal assisted therapy, animal assisted activities and emotional support animals. These terms are often used interchangeably in the research, so it's really hard to know exactly what effects there are. Now, when you look at the animal assisted research, what you see is when animals are involved, there tends to be more participation, there tends to be less dropout. People really like being around animals. However, animal assisted therapy, just like music therapy, uses the animal to achieve a particular goal. So such as using a dog and having someone train the dog in order to learn consistency and assertiveness and emotion management. Because training a dog can be frustrating sometimes, so the animal actually serves as an integral part of the learning process, of the therapeutic process. It's not just there to provide comfort, it's not just there to provide encouragement for the person. Animal assisted activities or aaa are activities in which an animal is present, like using horses when people are processing trauma. Sometimes petting a horse can help people feel more secure while they're processing their traumatic memories. The horse is very calm and unwavering and doesn't, unlike a dog that tends to respond to your emotions quite readily. Horses tend to be a lot more stoic and can help the person feel more grounded while they're processing traumatic stuff. So anyway, again, animal assisted therapy as of yet doesn't have a significant base of high quality research for the treatment of depression. Now, there is other research for using animal assisted therapy in other situations, but for the treatment of depression really is lacking right now. Likewise, communication or relationship skills. This is another technique or intervention that is not well studied. I guess it's one we just take for granted that we're providing and services. But a lot of people who feel depressed may have developed that sense of hopelessness and helplessness because they didn't learn to articulate their thoughts, wants and needs. They didn't learn to communicate what they needed, so they didn't get their needs met, which left them feeling hopeless and helpless. Or they may not have learned how to set and maintain healthy boundaries. So they either have boundaries that are too strong and keep everybody out so they feel isolated, or they have boundaries that are too weak and they feel like people are always invading their space and walking all over them. So communication and relationship skills are tools that are really important in the treatment of depression. However, there is Unless I was just using all the wrong keywords, there is very little specific research that addresses the impact of communication skills and relationship skills training and depression improvement. And finally, family therapy. Current evidence base is still too heterogeneous and sparse to draw conclusions on the overall effectiveness of family therapy in the treatment of depression. This is according to the Cochrane Database, which this is another one of those things that there's an entire field of family therapy. We know that family therapy can be really helpful and useful. So why there's not more research looking specifically at the impact of family therapy on depressive symptoms of people in the family is very befuddling to me. Depression represents an imbalance of neurochemicals, either as the direct result of a loss or due to ongoing unrelenting physical or emotional stress. Effective treatment for depression often requires a variety of interventions to address all of the underlying biopsychosocial issues. It.