How to Treat Depression with Medicine and Positive Discussion
Dr. Jack Krasuski and Dr. Jeff Bostic meet after Dr. Bostic’s presentation at the Oasis 2019 Child and Adolescent Conference to discuss highlights of his talk about depression-related updates for 2019.
Dr. Jack Krasuski: Dear colleague, welcome. It’s Dr. Jack here with Dr. Jeff Bostic. Dr. Bostic is going to talk to us about depression and some highlights from 2019. Dr. Bostic, over to you. Just tell us whatever you think is the most important.
Dr. Jeff Bostic: The big thing that’s going on, as you know, we’ve always appreciated the combined treatment, if you will, some kind of psychotherapy such as cognitive behavioral therapy plus the medicines work better than the medicines alone. Okay, great. But what really has turned out to be very pertinent about this is people like Abdalla (sic), who has been doing research now for the last couple of years, has illuminated, that it’s like the stress and the distress that people experience. You’ve got to really do something about that also, so all the CBT kind of tactics and strategies that people learn are great, but it’s similarly like exercise, coping with stress, all those things turn down the damage that the stress and distress is doing to your nervous system so that the medicines can then be most helpful.
We’re increasingly appreciating that it’s not like uh-oh, someone’s come in and they have a problem, so we can give them a medicine that will perturborate (sic) their system and get them all better again. It’s like, you’ve got to go after both what’s leading to them being vulnerable to having this condition as well as also giving them [00:01:16] _agent?_ stuff to frankly help them repair their brain, to trigger the formation of new brain cells while you’re teaching them the strategies to burn the right tracks in these new brain cells that they’re driving from being on these medicines to really get the most benefit.
Dr. Jack Krasuski: I love that conceptualization because the way I look at psychiatric disorders, they’re really the culmination of a life that’s gone off balance in some way, but there’s a whole history to it. How do you get to the point of needing to see a psychiatrist? By giving someone a pill, yes, it can certainly reset the brain, but all of those vulnerability factors, risk factors are there. Then, how do you address them directly? I’m so pleased that we’re waking up to that.
Dr. Jeff Bostic: We were joking about it today when we were talking in the conference, which is an extremely good experience because everybody comes with their different things that they’re already learning and so concretely one of the things that we’ve come to appreciate is it’s not just like the cognitive behavioral kind of therapy strategies that you use to manage when you feel depressed. It’s turning into probiotics. It’s like we know that the second biggest area of serotonin receptors after the brain is the gut. Perturborations (sic) there, differences there, anomalies there probably increase your vulnerability. There is this whole biological spectrum of how vulnerable you are to whether it’s depression or a variety of other psychiatric conditions and there is environmental stuff.
The point is first you want to target both, but it’s like you want to target both a lot. It’s what they eat. What are we doing about sleep? We’re spending more of our time now talking about different environmental things that people can do to ensure that they’re sleep is stable and good quality, again, so they’re in the best place to benefit from the medicine treatments, and the same thing, again, with exercise. It’s become a huge variable. We’re seeing it both with team sports and individual stuff. It really diminishes one’s vulnerability and/or helps them recover more quickly when they can do even small, simple things.
Pressed for Time: Rapid, Effective Directions
Dr. Jack Krasuski: That’s wonderful. For the clinician who is really pressed for time, and almost everyone is pressed for time, what is a good entry point to start, even during a med administration session, maybe limited to 20 minutes, what can a clinician do realistically that will start moving that patient in that direction? What’s your advice?
Augment Depression Medicine with Focus on the Positive
Dr. Jeff Bostic: Two things. The clinicians are typically very smart and adept at going through the algorithm of what medicine would be the best fit for this patient. That’s something that people are really good at doing very quickly. We jokingly talk about the relationship being the thing, but increasingly research has demonstrated this over decades that you only get so much better on the medicine, but you get a lot better by just seeing the psychiatrist and by keeping up with it.
So here’s the relevant clinical part. We’re looking to do two things differently. First and foremost, we’re moving away from: How’s your sleep? How’s your depression this week? Are you still feeling as suicidal? Historically, we would go through the criteria for the pathology and that would be the focus of the conversation. Now still, we want to capture that, but you can capture that quickly with rating scales that they fill out in the waiting room, typically it’s what are the big things?
Then augment that with what we’re now calling focusing on the positive, which is you should have something that you’re conversing about with every patient about something that they’re growth oriented about, whether it’s sports, music, if they’re interested in movies, whatever it might be, so that there’s something that they’re burning in their brain other than every time I see the psychiatrist I associate that with my depression. That thing I think is helping us to move into a more health promoting aspect of living with these chronic mental illnesses. You don’t typically have one burst of three months of depression in your life and then you never see it again. You may have wide intervals in between them, but it’s like doing all the healthy things in between should diminish the frequency of episodes and the intensity of them.
How Medicine Makes the Patient Better
Building that in and our other joke has recently been [00:05:09] oh, perma, you know the positive emotions. Specifically, what they’re doing the med check, how’s the medicine affecting your joy, your serenity, your positive emotions? Not just the negative ones. How’s it working with your engagement with others? How about your relationships? Are you noticing that those are better or worse? How about your ability to accomplish stuff at school? Meaning, do you feel different? Does in mean something to take a medicine? Because kids will say, oh, I’m worried that this is changing me as a human being. It’s like, oh really? Maybe, but is it doing things that are helping you to explore things that you didn’t think about doing before because you feel more courageous or you feel better and more confident, like you’re open to other domains.
Dr. Jack Krasuski: I love it. I just wrote a blog post article called Nurturing Our Patient’s Resources.
Dr. Jeff Bostic: Yea.
Dr. Jack Krasuski: And I think people have some resources that they’re already using. Other resources are latent, but we never say, well, what else? What can your sister do to maybe help out and give you a little bit of childcare so you can have some respite? Just as one example, we don’t focus on the resources, I mean, the strengths and positive things that are there, but no one really thought about it. As clinicians we can say, hey, what if we nurtured those things? It may take a little while. Some things are on the surface. It’s like, just go ahead and do it. Other things, it takes a little bit of work to bring them up.
The Blooming Flower in a Flourishing Garden
Dr. Jeff Bostic: I haven’t thought of it that way before, but I’m going to steal that brilliant metaphor because we always joke about or talk about looking at our patient’s lack of flowers and we’re waiting for them to bloom and to bud. Now, our treatment focus has shifted toward, what can we do with the soil? How can we do management stuff to help this plant grow? But better, your analogy is more to people are a garden. They have musical propensities. They may have interest in the arts or sports or how they connect with other people. It’s like, you have things blooming all the time in your garden.
Dr. Jack Krasuski: And if they’re not blooming, there are things you can do. You check the acidity or alkalinity of the soil. You get some mulch.
Dr. Jeff Bostic: But it’s to be thinking about like, I want a bunch of different things in this human being, particularly young people to bloom so that they can make the best decisions for their life, career wise, relationship wise. Thinking about that, these latent things out there that we haven’t necessarily addressed, I think, is actually a very smart idea.
Dr. Jack Krasuski: I like what you just said that expands my thinking. Again, a person isn’t just a flower. They’re a whole garden because there are so many facets to us. We may be blooming here, but not really blooming there. There are ways of really expanding our awareness in ways that a person can in some way flourish. I think that’s another really good word that is good to incorporate into our clinical terminology.
Dr. Jeff Bostic: I totally agree, so thanks for explaining the idea.
Dr. Jack Krasuski: I loved your talk. Thank you so much. Thanks for being part of this.
Dr. Jeff Bostic: It was great.
Dr. Jack Krasuski: Alright, thank you.
Dr. Jeff Bostic: Thanks.