September 6, 2023 • 16 mins
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Join us on a journey of hope and healing as we delve into the world of nonpharmacologic treatment options for depression. In this insightful podcast, we explore holistic approaches, therapies, and lifestyle changes that offer powerful tools for managing and overcoming depression.
Our Guru’s share their experiences, knowledge, and practical advice. Discover the transformative potential of mindfulness, cognitive-behavioral therapy, exercise, and dietary adjustments. Learn how small changes in your patients routine can have a profound impact on their mental well being.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Thanh (00:01):
Welcome to the Y in Psychiatry,
Dr. Amayo (00:03):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:06):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:10):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:20):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(00:43):
Only on The Y in Psychiatry.
Dr. Amayo (00:47):
All right, welcome back to the Y in psychiatry.
Today we'll be continuing fromthe algorithm of depression.
And just a quick reminder, lasttime we talked about, why to
treat depression, the steps indiagnosing depression, and the
first step you want to thinkabout, again, it is your host,
Dr.
Amayo C/L Fellow, and I am herewith my co-host, Dr.
(01:11):
Handratta.
Dr. Handratta (01:13):
Hello guys, how are you?
Dr. Amayo (01:15):
Attending extraordinaire.
And today we'll be talking abouthow to select a treatment for
depression.
Dr.
H.
So what are the first steps doyou normally take if you wanna
treat depression.
Dr. Handratta (01:28):
So we all struggle with intimacy.
We all struggle with ouremotions, right?
Oh yeah.
Sometimes we cannot express ouremotions, though we feel it,
right?
So psychotherapy definitelyhelps us to open up and get
inside.
Into our own emotions because ifwe understand our own emotions,
we can understand our patient'semotions or our friend's
(01:50):
emotions or family members'emotions, right?
Alright, so now the questionthat Miracle asked, like what
do, what are the steps that wetake when we are treating
depression, right?
So this is not based on any bookor on research data.
So we basically tailor ourtreatment depending on the
situation, right?
The situation that caused thedepression.
(02:12):
Is it a psychosocial stressorthat is going on, or is it
biological right?
Is a patient having anunderlying medical condition
that is precipitating thedepression or it's actually
related to the lifestyle, peoplebasically not sleeping well or
drinking a lot of alcohol orusing drugs.
So it Totally depends upon whatis the situation and the
(02:32):
circumstance, right?
So it's very important tounderstand that because then you
can tailor your treatment andyou can see what exactly the
patient needs instead of justwriting a prescription and
sending the patient out.
The second thing is, I believein combining medication
management with psychotherapy.
So whenever you are talking to apatient about medication
(02:52):
management, psychotherapy, makesure that the patient is
involved in the treatment,right?
Do not tell the patient, this iswhat I'm going to do.
Tell the patient, Hey, this isthe information I'm going to
give you, and we both are goingto work together and you are
gonna make the decision.
You are gonna be in the driver'sseat.
I'm going to be actually sittingright next to you and guiding
you'cause it's important for thepatient to realize that they
(03:14):
have the control,
Dr. Amayo (03:16):
Why does psychotherapy work, or how does
it work with depression?
Dr. Handratta (03:21):
Psychotherapy, I considered it to be the backbone
of treatment, because if you donot treat the underlying cause,
then using a medication is morelike a bandaid, A person has to
actually understand actuallywhat exactly is going on, what
is causing the depression, orwhat is making them feel the way
they are feeling, because thisusually helps you to develop
some coping strategies.
(03:41):
That basically means that weknow from our previous episode
on network that in depression,you're stuck in the default mode
network, You're ruminating, youare isolating, you're avoiding
you are crying.
But psychotherapy, what it doesis that it usually helps switch
the network.
Going from a default modenetwork into a central executive
network so that you get controlover your life.
You change the cognition, theway you think about life, the
(04:05):
way you think about psychosocialstressors in your life, right?
And that is why psychotherapy isextremely important.
So our goal is actually to makethe patient self-reliant without
medications Now it's totallydifferent if the patient had
three or more episodes ofdepression than according to the
research data, they have to bein an antidepressant for the
rest of the life, But the firstand the second episode of
(04:26):
depression, you have a duration,actually, like an approximate
duration, how long the patientcan continue the medication, and
that makes them feel better,saying that they will not be
reliant on the medication therest of their life.
Dr. Amayo (04:37):
So one of your first steps in picking a treatment for
a patient with depression isunderstanding the factors
surrounding it.
Like if it's an acute socialstressors, involvement of
substance, or a medical cause.
And then if primary, from socialstressors, and mild then you
would stress using psychotherapyas it can help in change those
neuronal pathways, thoseautomatic pathways and
ultimately resulting in patientsresulting in a more resilient
(05:00):
pathway of the network.
Dr. Handratta (05:01):
Exactly.
and a part of the psychotherapyalways should start with
psychoeducation, whateverpsychiatric disorder you are
treating, psychoeducation shouldbe a very important part of the
treatment.
Because if you're notpsychoeducating the patient,
then it's basically, I considerthis to be a type of
psychosocial malpractice, Sopsychoeducation has to be good.
Dr. Amayo (05:21):
Why?
Dr. Handratta (05:21):
Because the thing is that people like to
understand what is going on andthere are very few providers who
sit with the patient and discussthat.
For example, if you go tointernal medicine, you go to
oncology.
Other fields of medicine, thephysician will sit and describe
to them what exactly is goingon, right?
So the patient has anunderstanding.
Otherwise, what do the patientsdo?
They go on doctor Google, andthey basically search things.
(05:45):
Sometimes actually they get theright information.
Sometimes, many times they getthe wrong information that is
further going to increase theirstress, So it's very important
actually to educate because, andthen plus you educating somebody
about something is more humane,right?
You're basically like taking thecondition seriously.
You're basically telling thepatient, Hey, it's not your
(06:05):
imagination.
that is something biological,which we can treat it right?
There's no cure, but we can helpyou.
So I always say actually, likethe medication that we prescribe
and the other treatment, it'snot it's not a happy pill.
I usually tell them, it's gonnamake you less miserable than how
you're feeling now.
So giving that right kind ofexpectation is also very
(06:25):
important.
That's why psychoeducation playsso such an important role
because you don't wannaprescribe when the patient goes
and says, Hey, I'm gonna be backto a happy no, you will be
actually less miserable.
And it's it's the steps that wetake.
It's a baby step, right?
Yeah.
Because I do not know whatnormal is.
Dr. Amayo (06:42):
So besides, psychotherapy, what else do you
keep in mind?
Dr. Handratta (06:47):
Other things are like exercise.
Which, and that is research dataon aerobic exercise and its
antidepressant effect.
Dr. Amayo (06:53):
So when you're exercising on being bros,
Dr. Handratta (06:56):
Yes, I've ex exercise being bros.
Being bros is like socializing,right?
You are actually getting out ofyour default mode network and
you are actually getting intoyour central executive network.
Because people With depression,there is no bros actually,
they're isolating inside theirhouse, So you are absolutely
right.
So being bros and going out,exercising your, basically
(07:18):
engaging your central executivenetwork, right?
Socialization is also a veryimportant part, We are to
encourage the patients, actuallycall your family member, call
your friends, get out of thehouse, take a walk, Go babysit
somebody's pet or dog becausethat will you will go with the
dog and go for a walk.
See people around you, Soexercise socialization should be
(07:39):
an important part of thetreatment, Healthy eating, So I
always look at the BMI.
I talk to the patients nottelling them what to do, I don't
want to patronize the patient, Iask them like, what does your
eating lifestyle looks like?
And then actually telling thepatient that we all actually
don't know what healthy eatingis.
(07:59):
Is it okay for me to actuallyrefer you to see a nutritionist,
Because we have all, everythingthat is available we don't
utilize the resources that wehave around us.
Because we know that obesity ispretty common in patients who
have psychiatric disorders, anda lot of our medications can
cause metabolic side effects.
So this is, so prevention isalways better than cure, So this
(08:22):
is a preventative approach Thenif the patient has comorbid
attention problems, Refer thepatient for executive function
coaching, which helps them withthe executive functioning.
Again, you are recruiting thecentral executive network.
Dr. Amayo (08:35):
What is that?
Executive function coaching?
Dr. Handratta (08:38):
So executive function coaching is basically,
these are life coach seepatients with attention deficit
disorder, who usually teach themorganization and planning
skills, how to manage your time,how not to be impulsive, So that
helps to organize the life,right?
So executive function is nothingbut planning and organizing.
Planning for the future.
(08:59):
And sleep is extremelyimportant.
That is neglected by manybecause the residual stuff,
after you treat depression isbasically cognitive impairment
and insomnia, Sometimes as youtreat the depression, the
insomnia gets better, but manytimes insomnia is totally
separate than the depression, soyou have to pay attention to
that.
(09:19):
So educating the patient aboutthe circadian rhythm, why is it
important to have a good sleepschedule?
And in this electronic age, weare always actually on our
electronic system, So the sleepwake cycle is disturbed when you
go out.
Everything is so bright at nightthat will actually like disturb
your sleep wake cycle, They saythat people who are in a rural
areas have a better sleep wakecycle because when you look at
(09:41):
the sky, it's dark.
Yeah.
City, if you look at the sky,it's bright, Because of all the
light.
So it's important actually toeducate about a good sleep wake
cycle, right?
So these are actually likehealthy lifestyle choices.
Dr. Amayo (09:52):
So you're saying exercise, socialization, sleep
optimize all those.
And this is all before you evenstart thinking about
psychotherapy andpharmacotherapy.
Dr. Handratta (10:03):
There is plenty of other things.
I have a list actually of thingsthat I basically do before I
start the treatment because mypsychotherapy has started
actually the time I start seeingthe patient.
So I've already started psychoeducation.
And these are the things thatyou will not see on the internet
actually.
And these are the things that wedo not focus on.
Most of us are actually havesuch a busy schedule that we
(10:25):
just write a prescription andsend the patient out.
And when you educate about thesethings, a lot of times patients
want to see you again.
Because you are not one of thosepill pushers.
Another things actually that Iwant to make sure is to rule out
sleep apnea.
This is missed a lot of times,Always ask the patient about
sleep apnea.
So the best way to do it is do aSTOP BANG score.
(10:47):
Very easy to do pretty quick,and the scores will basically
tell you whether the patient ismild, moderate, or severe apnea.
And then you can refer them tosleep study.
And the sleep specialist, whenthey look at the stop bank
score, they will like, okay, sothis like most likely patient
has sleep apnea, Or you canactually use pulse oximetry.
So that's an easiest way ofactually knowing whether you
(11:08):
have sleep apnea is pull thepulse oximetry, it records your
oxygen saturation on your cellphone.
So when you wake up, you can seehow many number of times you've
had desaturation put that datain your referral, send it to the
sleep specialist, So sleep apneais very important to treat
because if you don't treat sleepapnea, it can lead to treatment
resistant depression.
Dr. Amayo (11:27):
Why?
Dr. Handratta (11:28):
What happens is that when people have sleep
apnea, they have micro episodesof waking up multiple times in
the middle of the night, So youdon't have a good consolidated
sleep.
And most of our memory formationactually happens.
A consolidation happens in thenon-REM sleep, There's also a
data which shows that whenpeople have insomnia, there's an
increased risk of amyloid betadeposits in the brain, what
(11:50):
happens is that your neurons areactive during the daytime, but
when you're sleeping, yourneuron go to sleep.
But your glia, the astrocytesbecome active.
Those are the cleaners.
So what they do is that theyclean up all the gunk that is
accumulated during the daytimethat is produced by the neurons.
You don't clean that up.
You cause pre-radical damage.
So that's why sleep isimportant.
(12:12):
So your glia can actually work.
So these are some of the thingsthat I talk to the patient
about, and when patients ask mequestions I describe, I explain
to them as to like, why is itimportant?
Because there's always a why.
That's why we made thisparticular podcast.
right?
Why in psychiatry, And then likewhen you are seeing patients
(12:33):
always use scales, scales areextremely important because it
tells you what the baselinelooks like and how they are
responding to the treatment.
Dr. Amayo (12:41):
So scales for the depression or for to rule out
other illness.
Dr. Handratta (12:47):
It's actually for depression.
So what's the scale that you useMiracle for when you're seeing
patients with depression?
Dr. Amayo (12:53):
PHQ nine is usually what I use.
Yeah.
Dr. Handratta (12:57):
And that's like a scale.
It's patients can actually do itby themselves, right?
Yeah.
So PHQ nine is a great tool touse, but at the same time, I
also want the patients to do amood disorder questionnaire or a
rapid mood screener, right?
Because that will give you anidea whether you need to go into
detail and ask the patient aboutmania or hypomania, So if the
(13:19):
rapid mood screener or mooddisorder questionnaire is
negative, then you're ruled outmania or hypomania.
But if it's positive, then youcan go in detail.
So at least you know whether youneed to focus on mania
hypomania, right?
Because the treatment completelychanges.
And as we talked about in theprevious episode, every five
patients diagnosed with majordepressive disorder in a primary
care office, one will haveundiagnosed bipolar disorder,
(13:42):
And most of the bipolardisorder, the present with
depression.
So they usually get missed.
Then the depression scale willvary depending upon what are you
treating.
For example, a patient withschizophrenia, you can't use PHQ
nine because schizophreniapatients have negative symptoms,
right?
PHQ nine actually talks aboutneuro vegetative symptoms.
(14:03):
So you use something calledCalgary Depression Scale in
patients with schizophrenia Allthese are available on the
internet and it tells youexactly how to score it,
Patients who have postpartumdepression, you can use PHQ
nine, But the scales that ismost commonly used is the
Edinburough Postnatal DepressionScale, And your treatment
depends upon what the score is.
The next one is patients whohave H I V, they have a lot of
(14:24):
neurovegetative symptoms.
So you basically use somethingcalled Beck depression inventory
for primary care.
Which basically just does notfocus on the neurovegetative
symptoms.
More on the affective symptoms.
Geriatric population, you usegeriatric depression scale
because sleep, appetite weightis a problem in the geriatric
patient, even if they don't havedepression.
so it basically just focuses onthe affective symptoms.
(14:47):
Last but not the least alwaystry to differentiate apathy from
depression.
And we'll talk about apathy inone another podcast because
there are two differentconditions and SSRIs and SNRIs
can make apathy worse.
So use something called apathy,evaluation scale.
Dr. Amayo (15:03):
Okay.
So when treating depression,make sure you utilize your
scales and depending on thepopulation, depending on
comorbidities use the rightscales and do not forget sleep
because we need sleep during oursleep.
That's when our brain gets toclean up and not sleeping leads
to a lot of risks to includeworsening depression and giving
(15:26):
you treatment resistance,depression.
Okay.
I think that was a very goodbeginning on how we treat
depression and other things wecan include besides, Zoloft.
Thank you very much.
And this has been the Ypsychiatry.
Dr. Handratta (15:41):
Perfect.
Thank you.
My brothers and sisters.
Katrina (15:49):
Thank you for joining us on today's episode.
our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
Welcome to the Y in Psychiatry,
Dr. Amayo (00:03):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:06):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:10):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:20):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(00:43):
Only on The Y in Psychiatry.
Dr. Amayo (00:47):
All right, welcome back to the Y in psychiatry.
Today we'll be continuing fromthe algorithm of depression.
And just a quick reminder, lasttime we talked about, why to
treat depression, the steps indiagnosing depression, and the
first step you want to thinkabout, again, it is your host,
Dr.
Amayo C/L Fellow, and I am herewith my co-host, Dr.
(01:11):
Handratta.
Dr. Handratta (01:13):
Hello guys, how are you?
Dr. Amayo (01:15):
Attending extraordinaire.
And today we'll be talking abouthow to select a treatment for
depression.
Dr.
H.
So what are the first steps doyou normally take if you wanna
treat depression.
Dr. Handratta (01:28):
So we all struggle with intimacy.
We all struggle with ouremotions, right?
Oh yeah.
Sometimes we cannot express ouremotions, though we feel it,
right?
So psychotherapy definitelyhelps us to open up and get
inside.
Into our own emotions because ifwe understand our own emotions,
we can understand our patient'semotions or our friend's
(01:50):
emotions or family members'emotions, right?
Alright, so now the questionthat Miracle asked, like what
do, what are the steps that wetake when we are treating
depression, right?
So this is not based on any bookor on research data.
So we basically tailor ourtreatment depending on the
situation, right?
The situation that caused thedepression.
(02:12):
Is it a psychosocial stressorthat is going on, or is it
biological right?
Is a patient having anunderlying medical condition
that is precipitating thedepression or it's actually
related to the lifestyle, peoplebasically not sleeping well or
drinking a lot of alcohol orusing drugs.
So it Totally depends upon whatis the situation and the
(02:32):
circumstance, right?
So it's very important tounderstand that because then you
can tailor your treatment andyou can see what exactly the
patient needs instead of justwriting a prescription and
sending the patient out.
The second thing is, I believein combining medication
management with psychotherapy.
So whenever you are talking to apatient about medication
(02:52):
management, psychotherapy, makesure that the patient is
involved in the treatment,right?
Do not tell the patient, this iswhat I'm going to do.
Tell the patient, Hey, this isthe information I'm going to
give you, and we both are goingto work together and you are
gonna make the decision.
You are gonna be in the driver'sseat.
I'm going to be actually sittingright next to you and guiding
you'cause it's important for thepatient to realize that they
(03:14):
have the control,
Dr. Amayo (03:16):
Why does psychotherapy work, or how does
it work with depression?
Dr. Handratta (03:21):
Psychotherapy, I considered it to be the backbone
of treatment, because if you donot treat the underlying cause,
then using a medication is morelike a bandaid, A person has to
actually understand actuallywhat exactly is going on, what
is causing the depression, orwhat is making them feel the way
they are feeling, because thisusually helps you to develop
some coping strategies.
(03:41):
That basically means that weknow from our previous episode
on network that in depression,you're stuck in the default mode
network, You're ruminating, youare isolating, you're avoiding
you are crying.
But psychotherapy, what it doesis that it usually helps switch
the network.
Going from a default modenetwork into a central executive
network so that you get controlover your life.
You change the cognition, theway you think about life, the
(04:05):
way you think about psychosocialstressors in your life, right?
And that is why psychotherapy isextremely important.
So our goal is actually to makethe patient self-reliant without
medications Now it's totallydifferent if the patient had
three or more episodes ofdepression than according to the
research data, they have to bein an antidepressant for the
rest of the life, But the firstand the second episode of
(04:26):
depression, you have a duration,actually, like an approximate
duration, how long the patientcan continue the medication, and
that makes them feel better,saying that they will not be
reliant on the medication therest of their life.
Dr. Amayo (04:37):
So one of your first steps in picking a treatment for
a patient with depression isunderstanding the factors
surrounding it.
Like if it's an acute socialstressors, involvement of
substance, or a medical cause.
And then if primary, from socialstressors, and mild then you
would stress using psychotherapyas it can help in change those
neuronal pathways, thoseautomatic pathways and
ultimately resulting in patientsresulting in a more resilient
(05:00):
pathway of the network.
Dr. Handratta (05:01):
Exactly.
and a part of the psychotherapyalways should start with
psychoeducation, whateverpsychiatric disorder you are
treating, psychoeducation shouldbe a very important part of the
treatment.
Because if you're notpsychoeducating the patient,
then it's basically, I considerthis to be a type of
psychosocial malpractice, Sopsychoeducation has to be good.
Dr. Amayo (05:21):
Why?
Dr. Handratta (05:21):
Because the thing is that people like to
understand what is going on andthere are very few providers who
sit with the patient and discussthat.
For example, if you go tointernal medicine, you go to
oncology.
Other fields of medicine, thephysician will sit and describe
to them what exactly is goingon, right?
So the patient has anunderstanding.
Otherwise, what do the patientsdo?
They go on doctor Google, andthey basically search things.
(05:45):
Sometimes actually they get theright information.
Sometimes, many times they getthe wrong information that is
further going to increase theirstress, So it's very important
actually to educate because, andthen plus you educating somebody
about something is more humane,right?
You're basically like taking thecondition seriously.
You're basically telling thepatient, Hey, it's not your
(06:05):
imagination.
that is something biological,which we can treat it right?
There's no cure, but we can helpyou.
So I always say actually, likethe medication that we prescribe
and the other treatment, it'snot it's not a happy pill.
I usually tell them, it's gonnamake you less miserable than how
you're feeling now.
So giving that right kind ofexpectation is also very
(06:25):
important.
That's why psychoeducation playsso such an important role
because you don't wannaprescribe when the patient goes
and says, Hey, I'm gonna be backto a happy no, you will be
actually less miserable.
And it's it's the steps that wetake.
It's a baby step, right?
Yeah.
Because I do not know whatnormal is.
Dr. Amayo (06:42):
So besides, psychotherapy, what else do you
keep in mind?
Dr. Handratta (06:47):
Other things are like exercise.
Which, and that is research dataon aerobic exercise and its
antidepressant effect.
Dr. Amayo (06:53):
So when you're exercising on being bros,
Dr. Handratta (06:56):
Yes, I've ex exercise being bros.
Being bros is like socializing,right?
You are actually getting out ofyour default mode network and
you are actually getting intoyour central executive network.
Because people With depression,there is no bros actually,
they're isolating inside theirhouse, So you are absolutely
right.
So being bros and going out,exercising your, basically
(07:18):
engaging your central executivenetwork, right?
Socialization is also a veryimportant part, We are to
encourage the patients, actuallycall your family member, call
your friends, get out of thehouse, take a walk, Go babysit
somebody's pet or dog becausethat will you will go with the
dog and go for a walk.
See people around you, Soexercise socialization should be
(07:39):
an important part of thetreatment, Healthy eating, So I
always look at the BMI.
I talk to the patients nottelling them what to do, I don't
want to patronize the patient, Iask them like, what does your
eating lifestyle looks like?
And then actually telling thepatient that we all actually
don't know what healthy eatingis.
(07:59):
Is it okay for me to actuallyrefer you to see a nutritionist,
Because we have all, everythingthat is available we don't
utilize the resources that wehave around us.
Because we know that obesity ispretty common in patients who
have psychiatric disorders, anda lot of our medications can
cause metabolic side effects.
So this is, so prevention isalways better than cure, So this
(08:22):
is a preventative approach Thenif the patient has comorbid
attention problems, Refer thepatient for executive function
coaching, which helps them withthe executive functioning.
Again, you are recruiting thecentral executive network.
Dr. Amayo (08:35):
What is that?
Executive function coaching?
Dr. Handratta (08:38):
So executive function coaching is basically,
these are life coach seepatients with attention deficit
disorder, who usually teach themorganization and planning
skills, how to manage your time,how not to be impulsive, So that
helps to organize the life,right?
So executive function is nothingbut planning and organizing.
Planning for the future.
(08:59):
And sleep is extremelyimportant.
That is neglected by manybecause the residual stuff,
after you treat depression isbasically cognitive impairment
and insomnia, Sometimes as youtreat the depression, the
insomnia gets better, but manytimes insomnia is totally
separate than the depression, soyou have to pay attention to
that.
(09:19):
So educating the patient aboutthe circadian rhythm, why is it
important to have a good sleepschedule?
And in this electronic age, weare always actually on our
electronic system, So the sleepwake cycle is disturbed when you
go out.
Everything is so bright at nightthat will actually like disturb
your sleep wake cycle, They saythat people who are in a rural
areas have a better sleep wakecycle because when you look at
(09:41):
the sky, it's dark.
Yeah.
City, if you look at the sky,it's bright, Because of all the
light.
So it's important actually toeducate about a good sleep wake
cycle, right?
So these are actually likehealthy lifestyle choices.
Dr. Amayo (09:52):
So you're saying exercise, socialization, sleep
optimize all those.
And this is all before you evenstart thinking about
psychotherapy andpharmacotherapy.
Dr. Handratta (10:03):
There is plenty of other things.
I have a list actually of thingsthat I basically do before I
start the treatment because mypsychotherapy has started
actually the time I start seeingthe patient.
So I've already started psychoeducation.
And these are the things thatyou will not see on the internet
actually.
And these are the things that wedo not focus on.
Most of us are actually havesuch a busy schedule that we
(10:25):
just write a prescription andsend the patient out.
And when you educate about thesethings, a lot of times patients
want to see you again.
Because you are not one of thosepill pushers.
Another things actually that Iwant to make sure is to rule out
sleep apnea.
This is missed a lot of times,Always ask the patient about
sleep apnea.
So the best way to do it is do aSTOP BANG score.
(10:47):
Very easy to do pretty quick,and the scores will basically
tell you whether the patient ismild, moderate, or severe apnea.
And then you can refer them tosleep study.
And the sleep specialist, whenthey look at the stop bank
score, they will like, okay, sothis like most likely patient
has sleep apnea, Or you canactually use pulse oximetry.
So that's an easiest way ofactually knowing whether you
(11:08):
have sleep apnea is pull thepulse oximetry, it records your
oxygen saturation on your cellphone.
So when you wake up, you can seehow many number of times you've
had desaturation put that datain your referral, send it to the
sleep specialist, So sleep apneais very important to treat
because if you don't treat sleepapnea, it can lead to treatment
resistant depression.
Dr. Amayo (11:27):
Why?
Dr. Handratta (11:28):
What happens is that when people have sleep
apnea, they have micro episodesof waking up multiple times in
the middle of the night, So youdon't have a good consolidated
sleep.
And most of our memory formationactually happens.
A consolidation happens in thenon-REM sleep, There's also a
data which shows that whenpeople have insomnia, there's an
increased risk of amyloid betadeposits in the brain, what
(11:50):
happens is that your neurons areactive during the daytime, but
when you're sleeping, yourneuron go to sleep.
But your glia, the astrocytesbecome active.
Those are the cleaners.
So what they do is that theyclean up all the gunk that is
accumulated during the daytimethat is produced by the neurons.
You don't clean that up.
You cause pre-radical damage.
So that's why sleep isimportant.
(12:12):
So your glia can actually work.
So these are some of the thingsthat I talk to the patient
about, and when patients ask mequestions I describe, I explain
to them as to like, why is itimportant?
Because there's always a why.
That's why we made thisparticular podcast.
right?
Why in psychiatry, And then likewhen you are seeing patients
(12:33):
always use scales, scales areextremely important because it
tells you what the baselinelooks like and how they are
responding to the treatment.
Dr. Amayo (12:41):
So scales for the depression or for to rule out
other illness.
Dr. Handratta (12:47):
It's actually for depression.
So what's the scale that you useMiracle for when you're seeing
patients with depression?
Dr. Amayo (12:53):
PHQ nine is usually what I use.
Yeah.
Dr. Handratta (12:57):
And that's like a scale.
It's patients can actually do itby themselves, right?
Yeah.
So PHQ nine is a great tool touse, but at the same time, I
also want the patients to do amood disorder questionnaire or a
rapid mood screener, right?
Because that will give you anidea whether you need to go into
detail and ask the patient aboutmania or hypomania, So if the
(13:19):
rapid mood screener or mooddisorder questionnaire is
negative, then you're ruled outmania or hypomania.
But if it's positive, then youcan go in detail.
So at least you know whether youneed to focus on mania
hypomania, right?
Because the treatment completelychanges.
And as we talked about in theprevious episode, every five
patients diagnosed with majordepressive disorder in a primary
care office, one will haveundiagnosed bipolar disorder,
(13:42):
And most of the bipolardisorder, the present with
depression.
So they usually get missed.
Then the depression scale willvary depending upon what are you
treating.
For example, a patient withschizophrenia, you can't use PHQ
nine because schizophreniapatients have negative symptoms,
right?
PHQ nine actually talks aboutneuro vegetative symptoms.
(14:03):
So you use something calledCalgary Depression Scale in
patients with schizophrenia Allthese are available on the
internet and it tells youexactly how to score it,
Patients who have postpartumdepression, you can use PHQ
nine, But the scales that ismost commonly used is the
Edinburough Postnatal DepressionScale, And your treatment
depends upon what the score is.
The next one is patients whohave H I V, they have a lot of
(14:24):
neurovegetative symptoms.
So you basically use somethingcalled Beck depression inventory
for primary care.
Which basically just does notfocus on the neurovegetative
symptoms.
More on the affective symptoms.
Geriatric population, you usegeriatric depression scale
because sleep, appetite weightis a problem in the geriatric
patient, even if they don't havedepression.
so it basically just focuses onthe affective symptoms.
(14:47):
Last but not the least alwaystry to differentiate apathy from
depression.
And we'll talk about apathy inone another podcast because
there are two differentconditions and SSRIs and SNRIs
can make apathy worse.
So use something called apathy,evaluation scale.
Dr. Amayo (15:03):
Okay.
So when treating depression,make sure you utilize your
scales and depending on thepopulation, depending on
comorbidities use the rightscales and do not forget sleep
because we need sleep during oursleep.
That's when our brain gets toclean up and not sleeping leads
to a lot of risks to includeworsening depression and giving
(15:26):
you treatment resistance,depression.
Okay.
I think that was a very goodbeginning on how we treat
depression and other things wecan include besides, Zoloft.
Thank you very much.
And this has been the Ypsychiatry.
Dr. Handratta (15:41):
Perfect.
Thank you.
My brothers and sisters.
Katrina (15:49):
Thank you for joining us on today's episode.
our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
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