Depression

“How can you listen to such sad stories all day long?” patients commonly ask me. To which I reply, “Because I know that people will get better over time.”

Training to be a psychiatrist is not for everyone. The residency is generally four years long, but many will continue on to fellowship, as I did for geriatrics and dementia. Every training program includes experiences in the clinic, medical hospital, and psychiatric hospital. We devote our entire third year just to the skills of psychotherapy, offering therapy to new clients and doing our own therapy or psychoanalysis. Over time, with mentorship and supervision, we explore our own biases and blind spots while learning to cope with complex and challenging clinical situations.

Depression is one of the most ancient diseases of humankind. The older term is “melancholia.” And though depression is often associated with a feeling of sadness, clinical depression, like many mental illnesses, is marked by a significant functional decline. I once read that psychiatrists historically borrowed the term “depression” from the Cardiology literature: namely, depressed ejection fraction of the heart, or the smaller “squeeze” that the heart pumps as blood flow decreases to the rest of the body. To evaluate functional impairment in someone who is depressed, I often ask, “What can you not do now that you could do before?”

“Am I depressed?” patients also ask me. To which I reply, “Tell me more.” I want to hear the story behind how the person is feeling. The term “depression” is often too vague and abstract. Many times, patients are feeling a more nuanced experience like loneliness, nostalgia, demoralization, moral injury, grieving, abandonment, or even fatigue and physical pain. Having an exploratory perspective can help uncover layers of feeling that the person may not yet be conscious of, and expression of these emotions by itself may help the person feel better.

And yet, it’s not what patients say that is the most important; it’s what they don’t say. Silence can be pregnant with meaning, or its very absence. This is why I feel that AI will never be able to capture a therapy session in full: there is just too much non-verbal communication in the room. Depressed people often talk less, so every year, there are a handful of times when patient care truly surprises me. It’s that phone call from a family member about a patient we thought was doing well, or a discharge summary about someone we didn’t know had a substance problem. I would like to think that my approach to care has been honed over the decades, but the margin of error in taking down a patient’s history will always remain. Depression care is no exception.

Every psychiatrist evaluates every patient for suicide… every time. My hope is that treating depression will ultimately save lives, in addition to relieving suffering. Suicide can be an unfortunate outcome of severe depression, and having past suicide attempts is the strongest risk factor for suicide. Going through the mental process of evaluating suicide risk for every patient often helps prioritize the urgency of safety, frequency of follow-up appointments, and referral to other resources such as psychotherapists.

Importantly, depression in health care providers often overlaps with burnout and wellness. We do not do enough to overcome the stigma of mental illness in our doctors, and it has continued to be an honor for me to help when someone reaches out. Wellness is more than just the absence of depression; it is the ability to lead our very best lives, however we define that. Employers as well as health care systems should be set up to support physicians in that journey, giving them a voice and access to resources that can help.

People sometimes wonder how depression relates to grieving. Everybody grieves differently and in their own way. Depression and bereavement can definitely overlap, but with grieving, hopefully the symptoms will not be as severe or focused on death, such as wanting to be with a deceased loved one. Questions I typically ask of a grieving person are: 1. What do you miss most about your loved one? 2. Did they die in peace, with dignity, and without pain? 3. If they were here next to us right now, what would they say to us? The main reason the grieving path is so varied is because the relationships between patients and their loved ones are likewise highly variable.

And what about older adults and children? At the ends of the aging spectrum, severe depression can lead to extreme presentations, including suicide, psychosis, and even major cognitive problems. Since safety may hinge on subtle and nuanced exam findings, the clinician would have to be extra astute, following up closely with the depressed patient. I once admitted an 85-year-old man to a psychiatric hospital’s dementia unit because he had gone to the police station after his wife died a month prior, asking them if they found his wife – he completely forgot that his wife had died.

Please reach out to your Primary Care doctor or colleague if you or a loved one are struggling with depression. The five best ways to feel better are: 1. Sleep well; 2. Eat well; 3. Exercise; 4. Socialize; and 5. Do something pleasurable or fun. And yet, I know there are people who are “allergic” to having fun, so my response to them is: 6. Do something meaningful or something you believe in. The science behind “purpose of life” activities is strong but easily forgotten. Of course, formal psychotherapy and biological treatments like medication work really well, too.

But, the most underutilized method to treat depression is changing one's environment. I have some patients who spend their entire days watching TV, ten hours per day every day, then come to an appointment with me in clinic every six months to refill their medications – for many years. Though they may get a bit better over time, I have to wonder if their quality of life has plateaued given the monotonous daily routine they have chosen.

For the rest of us, I recommend getting out of the house, getting some sun and fresh air, and seeing (no, smelling) some nature. Go to the store and save on that Door Dash. Mix it up and talk to your colleagues in the office. Maybe even take that trip you’ve always wanted to take. We have a lot more control over our environment than we give ourselves credit for – and we’ll feel a lot better the sooner we come to that realization.