Understanding why Depression is not just Depression
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- Опубликовано: 12 июн 2024
- There is a major problem with classifying all forms of depression as a major depressive disorder (MDD). I’ve been critical of our current classification system because it does not consider the underlying causes of depression. This usually results in all patients meeting criteria of MDD being offered the same treatments. To truly understand depression, we need to understand a lot more than just diagnostic criteria.
There are many ways that someone could meet criteria for MDD. The symptoms described in the DSM represent a range of depressive conditions but tell us very little about what type of depression the person is dealing with and what type of treatment would be most useful.
Time Stamps
Introduction: 00:00 to 02:17
History of Major Depression as a diagnosis: 02:18 to 05:22
Major Depression spectrum: 05:23 to 06:53
Neurotic Depression: 06:54 to 09:15
Melancholic Depression: 09:16 to 12:03
Mixed Depression: 12:04 to 14:38
Pure Depression: 14:39 to 15:57
Conclusion: 15:58 to 17:15
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In terms of drug therapy and physiology-oriented therapy, what I want to say is that there is currently an instrument called fNIRS in Taiwan, which is said to be able to distinguish between schizophrenia, bipolar disorder, and unipolar depression. So many people did brain wave tests and the doctor found that he was suffering from type 2 bipolar disorder rather than unipolar depression. After changing the type of medication, the depression improved significantly. In addition, a treatment method called rTMS or TBS is currently popular in Taiwan. According to the doctor's experience, choosing an effective magnetic stimulation method has helped many people improve their depression. All in all, many people who think they have unipolar depression are actually bipolar 2.
Sounds extremely helpful
That sounds very valuable if it can be/is used for diagnosis. I don't know whether my major depressive episodes are part of MDD or bipolar II, and to be honest I haven't ever even been *asked* about hypomanic symptoms, so it seems unlikely that it is something that has even occurred to the doctors. On top of that, I have lots of things that are "somewhat suggestive" of bipolar II without being diagnostic, most of the antidepressants i have tried have been largely unhelpful, and I haven't tried an anticonvulsant mood stabiliser (although i have had some success with atypical antipsychotics)
By all of which i mean to say i would probably be a sensible person to use this fNIRS on in order to guide treatment. I'm not holding my breath for it to be used widely here in the UK any time soon though...
This is what happened to me, that what seemed like pure recurrent depression turned into hypomania and then into a mixed state after taking an antidepressant. Now I'm staying well on lamotrigine. Thanks for interesting video 😀Greetings from Poland from Europe❤
I worked on psychiatry since 1980 until retirement in 2012. The last 10 years or so I worked in assisting with ECT and then again upon my return after 2 years on a casual basis. It was pretty predictable as who would really benefit from ECT based on the symptom profile that you pointed. Patient's who were in the hospital due to situational pressures such and family conflict and other relationship conflict, financial uncertainty, loss of financial support , homelessness, the.consequences of substance misuse and so forth generally benefitted little from ECT and were referred to ECT as they had been in hospital for many weeks and on many meds etc and the referring MD was basically at his or her wits end as to what to do with this patient who continued to endorse that they remained suicial. On the other hand, patients with what I called at the time "endogenous" symptoms here tended to be those who responded, often dramatically. The unit staff seemed to have a second sense about ECT candidates after years of seeing this play out again and again.
I agree you start to develop a clinical sense for who would benefit and who would not. ECT remains a valuable treatment and so does medication. One of my most important points here is that it's about choosing the right candidate. Appreciate the comment
ECT is criminal
Fantastic video! Love your perspective and I look forward to you content!
Thank you for being a part of the community
Hi dr Rossi, psych resident here. So I've heard of some research suggesting SSRIs can subtly reduce trait neuroticism in people. Recently, a small RCT comparing mirtazapine and SSRIs in depression linked high neuroticism to SSRIs being more effective and vice versa. The authors of the paper you're talking about, in my interpretation, say that SSRIs ought to have little, perhaps temporary, role in neurotic depression. Basically the views seem contradictory. Would love to hear your thoughts on the degree of utility SSRIs have in such people (either as a supplement to psychotherapy or on their own), who might get diagnosed with MDD, GAD, dysthymia.
Very easy to follow and understand. Keep the videos coming please.
Thank you, I appreciate you being a part of the community
One thing if always wanted to know: I’m very glad and thankful you make these videos, however, besides helping us, do you do these to stay extra sharp in your practice? In line with if you don’t talk about it, it might more easily forgotten?
I'm always reading and spending time getting better at my craft, I would say interacting with people on this channel has been a rich source of learning for me
Hello doc; thanks for the content! Very well thought as always!
Could you share the doi of the article you used the table with the spectrum from?
Thank you
are there any medications that do work for neurotic type depression? or if not, what is a more fitting treatment?
very nice video i liked it, id love some more reading material about this, all the articles i find are decades old
Psychotherapy is the best option for neurotic depression. I will put a list together of articles
This is all really helpful. Do you believe TMS could be helpful for one side of this spectrum rather than the opposite side? You mentioned melancholia as an indicator for intervention and am curious on what can be done for the neurotics out there
For neurotic depression the primary intervention would be psychotherapy. I would not be opposed to a trial of TMS for someone with neurotic depression who was in an active episode of major depression
Very informative. In case of mixed depression taking antidepressant, you said it will get worse , what does it mean? turns to manic episode or worsening the symptoms of depression?
I don't know if this will help. I had this happen when I took Effexor (venlafaxine), my diagnosis at the time was GAD with depression. After taking Effexor for a week or so I became hypomanic with high level enery but chaotic, constant ideas of making money, irritated, agitated, explosive anger (1-100 in seconds). Once I stopped the Effexor so did the hypomania. This is when my diagnosis changed to Bipolar 3, sometimes its called agitated/mixed depression or cyclothymia disorder. From my understanding it is becoming elevated to mania/hypomania or agitated not depressed.
I got diagnosed with bipolar 20 years ago from a general family doctor. I never had bipolar but I do have seasonal depression. I live in Michigan of course. I just take Wellbutrin in the winter time. Is it common for doctors misdiagnosed people?
I definitely fall into the neurotic / chronic and mostly anxiety symptoms, have been dx with pdd several times over. SSRI and therapy had me very stable usually going ~2 years without slipping into a MDD episode of a week or more. I probably should have stayed in therapy in between but usually only went once the episode happened and then for 2-3 months after it ended.
Thanks for sharing the story it's always good to hear some success stories from this community
@@ShrinksInSneakers Thanks! Just an n=1 the medication works really well for me despite being in the neurotic / persistent category.
The jury's still out on whether I have bipolar II or MDD (side note, I have BPD diagnosed and temporal lobe epilepsy...RIP my limbic system) but I would say I generally fit with your description of neurotic depression, although I do sometimes get periods of mixed features, again as you describe, but with me essentially vacillating between two of the types you propose.
The way I've been conceptualising depression in my head for a while now - my own depressions and others' - is somewhat similar, but with two, rather than four categories. Melancholic depression we have essentially conceptualised in the same way, although I think of it as a kind of classic bipolar I with all the mania subtracted.
The neurotic and mixed depressions I had been thinking of as one "mesolimbic pathway-online" entity, with atypical features, anxious distress, and sometimes mixed features, probably reflecting my own experience rather than what I've read. It essentially made a PDD-bipolar II hybrid (which I suppose could actually just be interictal dysphoric disorder). Strangely enough, your pure depression category is the one that I essentially omitted. Maybe this is because I have no clinical experience so it's excessively coloured by my own experiences, which entail generally being very intense with the occasional period where I've just fallen to bits, essentially.
What I am wondering is what tends to happen with the neurovegetative symptoms in pure depression? Do they go in opposite directions (e.g. eating less but sleeping more)? I'm having a bit of trouble picturing it clearly because it's like it's caught in between anorexia and hyperphagia, insomnia and hypersomnia, psychomotor retardation and psychomotor agitation, reactivity and nonreactivity...it almost makes it sound like euthymia: eating, sleeping, moving, and reacting neither excessively nor insufficiently - but that's clearly not what you're describing.
In pure depression we exclude the other possibilities, and we look for a consistent pattern of episodic depressive episodes that meet criteria for MDD. When the episodes resolve the person is euthymic and functional. The neurovegatative symptoms during the episode would be the same, it's the course of illness thats important here
Though not diagnosed as such, I think I've had Melancholic Depression for a very long amount of time and still has( BTW I've been diagnosed to Recurrent Depressive Disorder )... As I had severe psychomotor retardation, extreme Anhedonia and sexual dysfunction to the level that I was even unable to masturbate at all... Now I feel psychomotor retardation is improved, severe Anhedonia is still there, dysfunctionality and no overall change in mindset
Thanks for sharing the story and watching the video, if you haven't subscribed to the channel please do and spread the word about what we are doing here
Could you talk about fNIRS ?
Now i know i have neurotic depression since last year. Depression with anxiety symptoms after an extreme burn-out an relationship breakup together last year. The extreme stress brought me down with mayor panic attacks 11 months ago. Before i had the pure depression. Short episodes while functioning normal in between started from my 12 year. When I started Paroxetine around 24 th years i was stable till last year when all hell broke lose. Paroxetine does not do the job anymore. My question doctor is what threatment should work best for me? Thanks for the great content.
If you haven't found a good psychotherapist that you can form a good therapeutic alliance with that would be a good place to start. It's a lot like shopping for a car you have to find the one that fits you right. Hope this helps thanks for being a part of the community
@@ShrinksInSneakers Thanks doctor. Best wishes from the Netherlands
Are more categories really going to help us? There are so many inconsistencies with this classification system, not to mention a strong lack of empirical support for it. Many studies have found that anxiety is actually more common in melancholic depression, and have failed to demonstrate the supposedly superior response of melancholic depression to antidepressants. Furthermore, 'pure depression', as defined in this model, seems like a poorly defined category that acts as somewhat of a 'catch-all'. However, we know that depression is etiologically and symptomatically complex, and reducing presentations to simple categories provides very little in the way of clinical guidance
Hello Dr. Rossi. What type of depression would benefit from an MAOI? 🛡🔰⚕
Atypical
Besides the DSM, what would you recommend as a good textbook for psychiatric assessment and diagnosis?
great question, Goodwin and Guze's Psychiatric Diagnosis 7th Edition is a nice place to start
@@ShrinksInSneakers I appreciate your time and reply. I'm am psychiatric nurse practitioner student and find your videos extremely helpful.
Were does psychotic depression fall ?
I have severe anxiety and my depression is severwe as well. I wonder if part of this is because I was put on Benzos (for panic attacks only- my moods came from PMDD). and never taken off. That was over 15 years ago. I'm going through some very anxiety producing situations but my depression is also really bad. Just now, everything is worse. The only time I feel ok- for a few hours- is on Adderall. I don't have any good doctors. I don't think I ever have. I tell THEM what I thin will work or symptoms I might have and suddenly I have a script. I don't think I'll make it through this because I literally have no time to go through the side effects. About to lose eveything. Wish I had never been put on Benzos. I have no idea what to take and have about twenty bottles of antidepressants. I have no relief and it's pure hell.
I'm sorry to hear about the troubles and I agree long term benzodiazepine use has limited evidence for the treatment of anxiety disorders and many benzodiazepines are not approved for the treatment of GAD for example. I would talk with your doctor and come up with a proper taper and treatment plan. I believe you can get thought this
@@ShrinksInSneakers Not to bother you replyng again but I don't have- nor could I find- a GOOD doctor. I'm on medicaid and had a hard time eeven finding one who would fill my scrip9suddenly every doctor is reluctant)t. The one I did find reitred, would only refill 2 weeks, and I was literally on pieces of the pill, and taking Gabapentin, from trying to taper myself befire I found a nurse. I and instead of putting me on my normal amount (my tolerance is probably through the roof and I'm still on the same dose) he decreased my dose by 5ngs. I told him that was too fast but he doesn't listen. So, I really need to go back ojn antidepressants again. I'm not asking for medical advice so, hypotheicallt speaking, which would be better for GAD and through-the-roof anxiety: Effexor or Lexapro if one was on both in the past?
Supplement creatine for depression
Hi doctor. I have persistent depressive disorder (moderate) /neurotic depression. I have tried many ssris, Cymbalta, Abilify, lamictal, trileptal, and lithium. Even though I do not have manic symptoms, Lamictal was the only medication that worked for me but I had to stop it due to getting a rash twice. (Tried going on the medication 2 times.) As I really have nothing to lose, I am now trying Effexor as I have heard it’s helped people when other meds failed. I also go to therapy. Thank you for all the information in this video. My question is, what is the best treatment for someone with persistent depressive disorder? You mentioned that the typical ssris/ snris usually don’t work for people with this condition, so what is something that you have found that helps people with this disorder? I am interested in trying Spravato because I heard it effects glutamate, which is what Lamictal does as well, and figured if Lamictal helped me, maybe Spravato would too? Thank you and I look forward to hearing from you.
Do shrooms or something what you gotta lose
psychotherapy
Helps minimally @@user-ly2lv9nl5l
Try zoloft