March 10, 2025 • 27 mins
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Depression requires a comprehensive treatment approach addressing biological, psychological, and social dimensions for true healing. We explore the three essential components of effective depression management: medication, therapy, and behavioral activation.
• Depression categorized as mild, moderate, or severe, with treatment options varying accordingly
• PHQ-9 questionnaire serves as both diagnostic tool and progress tracker
• SSRIs (like Lexapro, Prozac, and Zoloft) serve as first-line medications with fewer side effects
• Antidepressants typically require six weeks at therapeutic dose to determine effectiveness
• Psychotherapy, especially cognitive behavioral therapy, proven equally effective as medication
• Combined medication and therapy approach provides superior outcomes to either alone
• Psychology Today website offers accessible therapist-finding tool
• Exercise (30-60 minutes, 3x weekly) prescribed as essential treatment component
• Behavioral activation through resuming enjoyable activities crucial for recovery
• Recovery is possible with comprehensive treatment even when motivation is low
Visit psychologytoday.com to find therapists in your area based on specialty, insurance coverage, session format, and more.
Production and Content: Edward Delesky, MD & Nicole Aruffo, RN
Artwork: Olivia Pawlowski
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Ed Delesky, MD (00:00):
Hi, welcome to Your Checkup.
We are the patient educationpodcast, where we bring
conversations from the doctor'soffice to your ears.
On this podcast, we try tobring medicine closer to its
patients.
I'm Ed Delesky, a familymedicine resident in the
Philadelphia area.
Nicole Aruffo, RN (00:14):
And I'm Nicole Aruffo.
I'm a nurse.
Ed Delesky, MD (00:15):
And we are so excited you were able to join us
here again today.
We just noticed that it was thefirst time in a long time that
we haven't had eggs.
Not because of the whole likehigh cost of living of eggs, but
we just didn't.
Nicole Aruffo, RN (00:28):
Well, we like didn't really eat breakfast.
Ed Delesky, MD (00:32):
No, no, we didn't.
Nicole Aruffo, RN (00:34):
We woke up I had a piece of toast and went
for a run, and then you went tothe gym and then it was like
late morning and then we kind ofjust like ate lunch.
Ed Delesky, MD (00:44):
We did.
We just went right for it.
Um, the fat rigatoni did happenlater in the week.
It was a surprise, a midweekdinner.
I was elated.
I came home and there it was.
I was so happy.
And last week we got sandwichesbecause that was what my dear
nikki requested, and so, so, soit was.
(01:05):
I mean, we're not going to wecan't dive into all of our shows
that we're watching because wewant to respect that maybe not
everyone is all caught up, butwe are very pleased and all of
it has been very entertaining sofar.
Would you agree?
Nicole Aruffo, RN (01:17):
I would agree .
Ed Delesky, MD (01:19):
And where are you heading tonight?
Nicole Aruffo, RN (01:21):
Tonight I'm heading to dinner.
Ed Delesky, MD (01:25):
We're going to laser wolf and I'm so excited
yeah I'll report back on how itwas notably, I am not joining,
which is totally fine.
You know you gotta.
You know, spread your wings, Iwill.
Chauffeur but going with myother boyfriend all right, you
and your girlfriends are gonnahave a great time.
Great time At least that's whatyou're telling me, and so I
(01:48):
can't wait to hear about it.
I've never been, so you'll haveto come back and give us a
review.
Nicole Aruffo, RN (01:51):
Hot off the press.
I think it's going to be great,and then I think we'll have to
go together.
Ed Delesky, MD (01:56):
Well, yeah, I can't wait.
That'll be great.
Do you have any other thoughtsabout anything that came up this
week?
Nicole Aruffo, RN (02:02):
Hmm, that came up this week.
Hmm, I don't think so.
It's a pretty standard week.
Ed Delesky, MD (02:08):
It was a pretty standard week.
Well, by the time anyone islistening to this, it will be
daylight savings again and wewill have sprung forward.
Every year, people are like, oh, we're getting rid of this.
You hate when I talk about thisfor some reason.
I'm excited that it's going tobe lighter out later, but I've
(02:31):
definitely become accustomed towaking up earlier.
Yes, I know that it willeventually get back together and
it will be easy again, but it'sjust.
You know, it's change andtomorrow is technically the
shortest day of the year, aswe're recording this on Saturday
.
Nicole Aruffo, RN (02:39):
And for like yawning okay.
And for like probably the firstsolid two weeks at least after
daylight savings time.
Eddie will just randomly belike wow, it's six o'clock, but
really it's five o'clock yeah Ido like to not like change.
Ed Delesky, MD (03:00):
Immediately change the the clocks in the
house, just to like.
Nicole Aruffo, RN (03:04):
We're like whoa, we're waking up at six,
but really it's like seven.
Ed Delesky, MD (03:12):
It's fascinating .
Ok, it's just like peopletogether make a decision and say
we are going to move the clocks.
And I understand why.
I had a long conversation overtext.
I talked to my dad about it andlike I understand why.
Now children a longconversation over text.
I talked to my dad about it andlike I understand why now
children would be going toschool and complete dark the
summer.
(03:32):
The sun would be coming up at4am and going down at 7pm.
So did you never realize that?
No, I never put two and twotogether.
Oh yeah, what life would belike if we didn't do this well,
wasn't it originally for likefarmers and stuff?
yeah, um, well, as anyone who'slistening will probably figure
(03:53):
out by now, like this isn't ourexact strong suit, I think it
might have been in world war one.
Um, for the farmers, who knows?
Unsure unclear at this point.
Send us some fan mail if you'reshaking your fist, farmer, and
you're a farmer, and you're likeyeah, I remember that world war
one, that's when they weredoing like you don't really need
sunlight anymore who doesn't?
Nicole Aruffo, RN (04:13):
the farmers why, they have those big lamps.
You know, everywhere, that'swhat people say.
Who are these people?
Ed Delesky, MD (04:22):
like these people on tiktok, you know I
could afford to pay attention tomore farmers, or I'm spreading
misinformation right now, whoknows?
Who knows?
Nicole Aruffo, RN (04:29):
Feeling wild on a Saturday, spreading
misinformation.
Ed Delesky, MD (04:33):
Yeah, well, that's about five minutes.
What do you say?
We get into it, let's get intoit, okay.
So what are we going to talkabout today, nick?
Nicole Aruffo, RN (04:39):
Today we're talking about treating
depression.
Ed Delesky, MD (04:42):
Yep.
So if you didn't listen to lastweek's episode, I would
probably recommend pausing,maybe going back and checking
that episode out so that youhave a really great foundation
about what we're talking abouthere in this episode.
But briefly, I just want tomention as a primer to continue
this episode is that depressionis a formal medical condition
(05:04):
and it goes beyond everydaysadness.
We talked a lot about what thespecific definition of
depression is last week,including its two week duration
of symptoms.
At least these symptoms can belong lasting and they can
disrupt daily life, andtreatment is crucial for
improving quality of life andreducing the risk of suicide.
(05:24):
So here we are Another triggerwarning we will be mentioning
suicide and passing here today,and so Nick, tell us a little
bit about how we differentiatetreatment options, like how are
we looking at depression?
Where do we get started?
Nicole Aruffo, RN (05:40):
So there's three kind of classifications of
depression mild, moderate andsevere.
So mild depression is the kindthat just involves some symptoms
without any kind of severedistress or impairment to your
life, and I think our intern'sgoing to chime in here.
(06:01):
Treatment options include kindof just like watching it
psychotherapy, and just likedoing things that are good for
you, like exercise and doingthings that make you feel good.
Ed Delesky, MD (06:14):
Yeah, why don't you tell us a little bit about
moderate depression?
Nicole Aruffo, RN (06:17):
Moderate depression is when something is
involving some more symptoms,and then this is when one might
have some suicidal thoughts, andthis is the time when an
antidepressant medication mightcome into play.
And then severe is really whenyou're having all these symptoms
that are so severe that they'reinterfering with your ability
(06:39):
to function and like youreveryday life, and this could um
treatment could be acombination of the
antidepressant medications andpsychotherapy.
Ed Delesky, MD (06:49):
Yeah, and one other thing that you'll probably
come across if you go to seesee your doctor or someone who's
taking care of you is somethingcalled a PHQ-9.
It stands for patient healthquestionnaire and it is a set of
questions that are written on apiece of paper or on a computer
and you answer them yourselfand it's essentially a mood
(07:11):
screening and it's also used asa scale.
So the higher the score, theworse your symptoms are, and
it's a way that patients cancommunicate with their doctors
in a way that might be lessintimidating Sometimes if you're
in the quiet of your own headand then you can write these
answers down, you cancommunicate how you're feeling a
little bit easier than openlyadmitting that maybe you're
(07:33):
feeling all of these things, andso you can track those things
over time.
Like just this last week I wasable to say, hey, your score was
a 17 when we started talking amonth ago, and now that you've
been doing therapy it's an 11and you should really celebrate
that and take solace that whatyou're doing is working.
So that's the PHQ and that'sreally how usually we get to the
(07:55):
mild, moderate and severecategories.
Nicole Aruffo, RN (07:57):
All right, let's talk about those
medications.
Ed Delesky, MD (08:00):
So medication is a can be an extremely important
piece of the treatment plan formajor depressive disorder, and
so there is a large umbrella ofmedications called
antidepressants, and under thatname and title umbrella there
are several different classes.
The most common class ofantidepressant medication is
(08:22):
called a selective serotoninreuptake inhibitor.
There are several of thesemedicines, and there's very
commonly prescribed medicines aswell, and if you talk to a lot
of people that you know, I bet ahandful of them probably take
these, but maybe they're justnot advertising it.
And so these selectiveserotonin reuptake inhibitors
(08:43):
are abbreviated SSRI and they goby different names.
And so for a fair and balancedconversation, we'll give the
generic name and some brandnames.
Some names go by escitalopramor Lexapro is the brand name,
paroxetine or Paxil, citalopramor Celexa, fluoxetine or Prozac
(09:07):
and sertraline or Zoloft, andthese are all very common
medications.
As I said earlier, they work byinhibiting the reuptake, as the
name might suggest, ofserotonin at the synapse.
So when two nerves arecommunicating with each other in
the brain, these medicines makefor an increased amount of
(09:30):
serotonin between those twonerves to communicate.
Functionally, what they do isthey help people cope with their
situation.
They themselves do not dealwith the problems that someone
may have that may lead to themhaving depression we will talk
about the thing that does thatlater but they may make it
easier for people to react tothose situations, and so it's
(09:52):
something we're going to talk alittle bit more about some
details.
But to continue on, there arealso serotonin norepinephrine
reuptake inhibitors.
This is a similar medicine, butinstead of just increasing the
amount of serotonin, it alsoincreases the amount of
norepinephrine.
Some common names includevenlafaxine, otherwise known by
(10:14):
the name Effexor, and duloxetine, otherwise known by Cymbalta.
There are other older atypicalantidepressants and other
related meds, including thingslike tricyclic antidepressants
and monoamine oxidase inhibitors.
These medicines aren't ascommonly used anymore.
(10:35):
They still may be used inspecific situations, but those
specific medicines tend to havemore side effects like dry mouth
, constipation, dizziness andurinary retention.
For tricyclic antidepressantsand the monoamine oxidase
inhibitors or you may have heardof MAOI these require a lot of
(10:56):
dietary restrictions, in the waythat you literally need to
change the food you eat becausethey may interact with these
medicines, which make them alittle cumbersome.
One other medicine that's verycommonly used, that's a
norepinephrine and dopaminereuptake inhibitor, is called
bupropion, and that's a verycommon one, well used and
tolerated for people who havedepression.
So with so many options, therecomes a point where you need to
(11:17):
select a certain antidepressant,and for mild to moderate
depression, there is a consensusout there that SSRIs are the
first line treatment becausethey have similar benefit to the
other medicines and they havethe least amount of risk
associated with them, includinga lesser amount of risk for side
(11:38):
effects, which tends to be verypositive.
There are the reasonablealternatives that we already
discussed, and generally theyall have similar effectiveness.
When it comes down to itbecause even the SSRIs there is
a long list up there that I gaveyou there are several different
factors that eventually helpnarrow down which one someone
may end up on.
Safety and potential sideeffects.
(12:00):
Some of them have certain sideeffects that others don't, and
so maybe you end up leaning oneway or another.
Certain phenotypes orpresentations of depressive
symptoms may do better withcertain types of antidepressants
.
If someone has otherpsychiatric or medical
conditions, that may pushsomeone to prescribe one
(12:22):
antidepressant over another.
A potential for druginteractions.
How easy is this med to use?
Is it dosed once a day, twice aday?
Do you take it in the morning?
Do you take it at night Once aday, twice a day.
Do you take it in the morning?
Do you take it at night?
Some people have a familyhistory of a relative having
success on certain medicines.
That's taken into account.
Occasionally Cost and insurancecoverage become issues and
(12:50):
previous responses to priorantidepressants, and when you
consider all of those, moreoften than not you land on one
specific medicine that workswell for the person.
Nikki, I've done a lot oftalking here.
Can you take us through someside effects, knowing that for
SSRIs there are many less sideeffects, but we want to have a
balanced conversation here andrecognize that sometimes there
(13:11):
are.
And so what could someone belooking out for if they are
concerned about a side effectfor an SSRI?
Nicole Aruffo, RN (13:17):
So some side effects include sexual
dysfunction, some reports ofwaking, dry mouth and also some
insomnia, but typically thesesymptoms are most often mild and
they'll go away within about aweek or two.
Ed Delesky, MD (13:35):
Yeah, I've recently seen that people
sometimes will say like, oh, Itook the medicine once and I
didn't feel great, so I stopped,and I appreciate that they came
back and told me that like thishappened yesterday and I'm
really happy they came back andinvited me to be a part of that
conversation.
But, at the same time, thesemedicines can be very effective,
(13:56):
but they have to be usedcorrectly, and so, if you do
have questions about sideeffects, ask your specific
doctor, because each of thosemedicines may have slightly
different variations, but that'sa very broad overview.
When thinking about thesemedicines, dosing is something
important to consider.
A low dose minimizes sideeffects, but it's important to
(14:17):
make sure that you're followingyour doctor's instructions and
increasing that dose when theysay so, whether it be increasing
at one week or in a month,because really a lot of times,
because those dose adjustmentstend to be very important,
because, quite literally, themost common reason for people
failing these medicines arebecause the medicines are at low
(14:40):
doses or they are usedirregularly, and so if you rely
on your doctor or nurse who'staking care of you, they can
help guide you through thatprocess to get you at the right
dose at the right medicine forthe treatment that you're
undergoing.
Nikki, these medicines have alot of conversation, like I
mentioned, that lady yesterday Isaw who said I took it one time
(15:03):
it didn't really work.
Tell us a little bit about thetimeframe, about how these
medicines work.
Nicole Aruffo, RN (15:08):
So it will take some time for these meds to
start working fully.
A lot of people will start tofeel better within maybe as
little as a week or two, butreally you have to give it a
solid six weeks beforedetermining if this medication
is actually making you feelbetter and working for you this
is such a common thing like I'llsee someone, I mean that's a
(15:30):
long time that is a long time sothat can be frustrating, and I
see why people wouldn't want tokeep taking it, you know.
Ed Delesky, MD (15:37):
Yeah, one thing I do worry about is to that
earlier point where if peopleare taking, let's say, they're
at six weeks, but they've beenat the lowest dose of Lexapro
and I worry that they'll losefaith in the treatment plan when
there are like two more stepsabove that before they actually
get to the treatment dose.
And so, specifically, this issix weeks at the treatment dose,
(16:00):
not at the starting dose, tosee if you tolerate the medicine
.
So that's an important bit.
And what other thoughts do youhave about that?
None, and I hear you.
I think that that can be atough thing for people to
appreciate, because there aremedicines that make you feel
different immediately, likespecific anti-anxiety medicines.
(16:23):
You take them and then inminutes you feel less anxious.
But this is the long run.
This is almost like a vitaminfor your mind, and so it's an
important part of the treatmentplan, but it ends up not being
everything.
Usually, when I'm with someonewho's getting the depression
talk from me I draw them atriangle and I draw them on.
(16:44):
One arm of the triangle ismedication, the next arm is
therapy and the third arm isbehavioral activation.
Let's talk about the second arm, let's talk about therapy.
So when I draw that triangle.
I really try to emphasize andsay that all parts of treatment
end up making for the mosteffective treatment of your mood
(17:05):
disorder.
In this case we're talkingabout depression.
Evidence will suggest thatPsychotherapy, and specifically
cognitive behavioral therapy,and medication are just as
effective as one another.
But there's also apreponderance of evidence that
suggests that if you use both atthe same time, you will have an
(17:27):
even more effective treatmentplan.
And so there are multiple typesof therapy.
There are multiple types oftherapy.
It is not just like you'resitting on a couch with someone
who has elbow pads and amustache, divulging your life
secrets to this person.
There are many different typesand we will define them here.
There is cognitive behavioraltherapy, or CBT.
(17:49):
This type of therapy identifiesand reshapes thought and
behavior patterns.
So let's see.
One example of this would besomeone who has a one-time
herpes breakout and they, forone year, are terrified of
engaging in a relationship withsomeone because they are so
(18:12):
worried that they will pass italong to someone else.
They've never had anotherbreakout.
The risk is relatively low, butthey will not engage with
another person.
They won't even talk to someonethat they're interested in
because they are so terrified ofthe possibility of giving
someone else herpes, and so onemight suggest that that is a
(18:34):
thought pattern that could bereshaped through cognitive
behavioral therapy.
There is interpersonalpsychotherapy.
I see this less frequently.
This focuses on relationshipsand interactions with others.
There is family, and manypeople have heard of this
couples therapy.
These address issuescontributing to depression and
(18:55):
family members or partners.
There is something calledproblem solving therapy, which
uses a systematic approach tosolve practical problems, and
there is psychodynamicpsychotherapy, and that is the
armchair sitting back with theelbow pads, with the person with
the mustache, because that isexploring past life events to
(19:17):
understand current behavior.
So that was a lot and somethingreally practical that we wanted
to share on this episode isselecting psychotherapy, or how
the heck do you get into therapyis the question, and so one
easy point of access could beasking your primary care doctor.
Many primary care doctors havebehavioral health consultants
(19:40):
that they work with or that theycould refer you to, and that is
a great access point.
So first stop your primary caredoctor.
The second stop is somethingthat I usually say every time
I'm having a conversation withsomeone, and you can literally
hop off of this episode afteryou listen to the full thing and
after, you share with a lovedone or a neighbor and you can go
(20:01):
to this website.
It's called psychologytodaycomand on this website you are able
to see a breakdown oftherapists.
You are able to see theircredentials, areas of special
training, their mantra, theinsurance coverage they take.
You can see what they look like, you can see do they do online
(20:21):
or in person, and in that wayyou can break down and find
someone that's in your area,that you might be most
comfortable with, accessible,affordable, and that you can be
proactive in that next step andengage in your treatment more so
.
Once again, that ispsychologytodaycom and it is
available to you right on yourphone, where you're probably
(20:43):
listening to us right now, andso those are two options to get
access as soon as either yournext appointment or today See
your PCP or psychologytodaycom.
One comment to say about now.
We've talked about twodifferent arms of the treatment.
We've talked about takingmedicines and we've talked about
therapy.
We've talked about how theyusually work better together,
(21:05):
and when you go to therapy, youtend to work through some of
these problematic thoughts thatmay be sticking around, causing
certain your symptom pattern.
Usually, it seems like therapytends to last longer because
you're getting to the root ofthe problem, but SSRIs can be
very helpful for those whosimply need them, and it's a
(21:28):
very important arm of treatment.
So I think the audience hasbeen hearing my voice so much in
this episode.
We've talked about if I drawthis triangle.
We've now talked aboutmedications, we've talked about
psychotherapy, but let's talkabout behavioral activation and
other aspects of treatment fordepression.
(21:49):
Take us through exercise.
Why is exercise so importantfor depression?
Nicole Aruffo, RN (21:55):
well, when you exercise, you get endorphins
, and endorphins make you happy,and happy people don't kill
their husbands.
Did you just come up with thaton the spot or is that?
No, it's from legally blonde.
Yeah, when the um like exerciseinstructor was on trial for
killing her husband oh my god,and then that's.
(22:17):
That was like elwood's defense,but then she was right.
It turns out that the daughterkilled him, but she thought that
it was the stepmom exerciseinstructor this has to do with
the perm right, it was juicy.
Yeah, yeah, I remember this,yeah um, yeah, so that's the
basis of that.
That exercise makes you feelgood, and because it makes you
(22:38):
feel so good, it's suggested tohave 30 to 60 minutes of heart
rate increasing exercise atleast three times per week.
Ed Delesky, MD (22:46):
And what about people who maybe aren't
exercising so frequently?
Nicole Aruffo, RN (22:50):
So that's just suggesting starting off
with more gentle activities likewalking.
You can take your dog for awalk.
Do some work around the houseand the garden.
You can do something, beproductive and active at the
same time.
You'll feel great.
Ed Delesky, MD (23:08):
Exactly, and I really would like to emphasize
this point because this issomething that, if you're
listening to this and you'relike I actually I do have
depression you can get out theretoday and this isn't just
something like, oh, I shouldexercise.
When you look at it in theframework of this is a treatment
plan.
This becomes a part of yourprescription and so now it's
non-negotiable, like if you wereto take a medicine every day.
(23:30):
If you have high cholesterol,you have increased risk of heart
attack and stroke.
You would probably take yourstatin.
If you had high blood pressure,you would watch how much salt
you have in your diet.
You would probably take yourblood pressure medicine.
If you have depression, you'reprobably thinking about taking
your antidepressant.
Finding and engaging in therapy.
Exercise becomes a part of yourprescription plan, and you
(23:53):
almost have to force yourself todo this.
If you're sitting at home, notdoing anything, ruminating in,
frankly, sadness, that won'thelp.
So as a part of yourprescription plan, you have to
engage in some sort of exercise,whatever it may look like.
This goes along with behavioralactivation.
(24:13):
Behavioral activation is aresumption of enjoyable
(24:33):
activities that were because ofthe depression.
Maybe you like to read and maybeyou stopped reading because of
the depression.
Perhaps you did yoga.
Maybe you get back to doingyour yoga or go on walks,
whatever that thing is.
Take a long moment and reflectwhat could I do that I used to
(24:54):
like to do, and then makeyourself do it.
This is so much easier saidthan done.
There are huge motivation andconcentration components to
depression and its pathology,but this is the point is that in
that triangle of treatment,you're getting out there and you
start doing those things thatyou once liked to do because
(25:15):
it's important and it will helpyou.
Is that easier said than done?
You think?
Nicole Aruffo, RN (25:20):
Yeah, probably.
Ed Delesky, MD (25:21):
And so, as we're wrapping up this episode here,
I really want to highlight thatthere is hope and there are
plenty of opportunities to beable to help yourself, even as
soon as you're done logging offthis episode, to treat
depression, if that's somethingyou're dealing with, also
several other mental healthdisorders, and so think of that
triangle the next time thatyou're considering how well are
(25:42):
you doing?
Are you taking medicine?
Have you thought about medicine?
Is that an option for you?
Have you engaged in therapy?
And how well are you doing onbehavioral activation and
exercise?
And if you work closely withyour doctor, you should be able
to see some improvement.
And if not, then keep going,keep trying to get help, because
(26:04):
there is hope for recovery outthere and feeling better from
what is a really common, reallyimportant illness to consider.
So thank you for coming back toanother episode of your Checkup
.
Hopefully you were able tolearn something for yourself, a
loved one or A depressedneighbor.
(26:24):
Please check out our Instagram,our website, send us an email
yourcheckuppod@gmail.
com.
Send us some fan mail and, mostimportantly, stay healthy, my
friends, until next time.
I'm Ed Delesky.
I'm Nicole Aruffo.
Thank you and goodbye, bye, bye.
This information may provide abrief overview of diagnosis,
(26:48):
treatment and medications.
It's not exhaustive and is atool to help you understand
potential options about yourhealth.
It doesn't cover all detailsabout conditions, treatments or
medications for a specificperson.
Thank you given or its use.
This content doesn't endorseany treatments or medications
for a specific patient.
Always talk to your healthcareprovider for complete
(27:18):
information tailored to you.
In short, I'm not your doctor,I am not your nurse, and make
sure you go get your own checkupwith your own personal doctor.
Hi, welcome to Your Checkup.
We are the patient educationpodcast, where we bring
conversations from the doctor'soffice to your ears.
On this podcast, we try tobring medicine closer to its
patients.
I'm Ed Delesky, a familymedicine resident in the
Philadelphia area.
Nicole Aruffo, RN (00:14):
And I'm Nicole Aruffo.
I'm a nurse.
Ed Delesky, MD (00:15):
And we are so excited you were able to join us
here again today.
We just noticed that it was thefirst time in a long time that
we haven't had eggs.
Not because of the whole likehigh cost of living of eggs, but
we just didn't.
Nicole Aruffo, RN (00:28):
Well, we like didn't really eat breakfast.
Ed Delesky, MD (00:32):
No, no, we didn't.
Nicole Aruffo, RN (00:34):
We woke up I had a piece of toast and went
for a run, and then you went tothe gym and then it was like
late morning and then we kind ofjust like ate lunch.
Ed Delesky, MD (00:44):
We did.
We just went right for it.
Um, the fat rigatoni did happenlater in the week.
It was a surprise, a midweekdinner.
I was elated.
I came home and there it was.
I was so happy.
And last week we got sandwichesbecause that was what my dear
nikki requested, and so, so, soit was.
(01:05):
I mean, we're not going to wecan't dive into all of our shows
that we're watching because wewant to respect that maybe not
everyone is all caught up, butwe are very pleased and all of
it has been very entertaining sofar.
Would you agree?
Nicole Aruffo, RN (01:17):
I would agree .
Ed Delesky, MD (01:19):
And where are you heading tonight?
Nicole Aruffo, RN (01:21):
Tonight I'm heading to dinner.
Ed Delesky, MD (01:25):
We're going to laser wolf and I'm so excited
yeah I'll report back on how itwas notably, I am not joining,
which is totally fine.
You know you gotta.
You know, spread your wings, Iwill.
Chauffeur but going with myother boyfriend all right, you
and your girlfriends are gonnahave a great time.
Great time At least that's whatyou're telling me, and so I
(01:48):
can't wait to hear about it.
I've never been, so you'll haveto come back and give us a
review.
Nicole Aruffo, RN (01:51):
Hot off the press.
I think it's going to be great,and then I think we'll have to
go together.
Ed Delesky, MD (01:56):
Well, yeah, I can't wait.
That'll be great.
Do you have any other thoughtsabout anything that came up this
week?
Nicole Aruffo, RN (02:02):
Hmm, that came up this week.
Hmm, I don't think so.
It's a pretty standard week.
Ed Delesky, MD (02:08):
It was a pretty standard week.
Well, by the time anyone islistening to this, it will be
daylight savings again and wewill have sprung forward.
Every year, people are like, oh, we're getting rid of this.
You hate when I talk about thisfor some reason.
I'm excited that it's going tobe lighter out later, but I've
(02:31):
definitely become accustomed towaking up earlier.
Yes, I know that it willeventually get back together and
it will be easy again, but it'sjust.
You know, it's change andtomorrow is technically the
shortest day of the year, aswe're recording this on Saturday
.
Nicole Aruffo, RN (02:39):
And for like yawning okay.
And for like probably the firstsolid two weeks at least after
daylight savings time.
Eddie will just randomly belike wow, it's six o'clock, but
really it's five o'clock yeah Ido like to not like change.
Ed Delesky, MD (03:00):
Immediately change the the clocks in the
house, just to like.
Nicole Aruffo, RN (03:04):
We're like whoa, we're waking up at six,
but really it's like seven.
Ed Delesky, MD (03:12):
It's fascinating .
Ok, it's just like peopletogether make a decision and say
we are going to move the clocks.
And I understand why.
I had a long conversation overtext.
I talked to my dad about it andlike I understand why.
Now children a longconversation over text.
I talked to my dad about it andlike I understand why now
children would be going toschool and complete dark the
summer.
(03:32):
The sun would be coming up at4am and going down at 7pm.
So did you never realize that?
No, I never put two and twotogether.
Oh yeah, what life would belike if we didn't do this well,
wasn't it originally for likefarmers and stuff?
yeah, um, well, as anyone who'slistening will probably figure
(03:53):
out by now, like this isn't ourexact strong suit, I think it
might have been in world war one.
Um, for the farmers, who knows?
Unsure unclear at this point.
Send us some fan mail if you'reshaking your fist, farmer, and
you're a farmer, and you're likeyeah, I remember that world war
one, that's when they weredoing like you don't really need
sunlight anymore who doesn't?
Nicole Aruffo, RN (04:13):
the farmers why, they have those big lamps.
You know, everywhere, that'swhat people say.
Who are these people?
Ed Delesky, MD (04:22):
like these people on tiktok, you know I
could afford to pay attention tomore farmers, or I'm spreading
misinformation right now, whoknows?
Who knows?
Nicole Aruffo, RN (04:29):
Feeling wild on a Saturday, spreading
misinformation.
Ed Delesky, MD (04:33):
Yeah, well, that's about five minutes.
What do you say?
We get into it, let's get intoit, okay.
So what are we going to talkabout today, nick?
Nicole Aruffo, RN (04:39):
Today we're talking about treating
depression.
Ed Delesky, MD (04:42):
Yep.
So if you didn't listen to lastweek's episode, I would
probably recommend pausing,maybe going back and checking
that episode out so that youhave a really great foundation
about what we're talking abouthere in this episode.
But briefly, I just want tomention as a primer to continue
this episode is that depressionis a formal medical condition
(05:04):
and it goes beyond everydaysadness.
We talked a lot about what thespecific definition of
depression is last week,including its two week duration
of symptoms.
At least these symptoms can belong lasting and they can
disrupt daily life, andtreatment is crucial for
improving quality of life andreducing the risk of suicide.
(05:24):
So here we are Another triggerwarning we will be mentioning
suicide and passing here today,and so Nick, tell us a little
bit about how we differentiatetreatment options, like how are
we looking at depression?
Where do we get started?
Nicole Aruffo, RN (05:40):
So there's three kind of classifications of
depression mild, moderate andsevere.
So mild depression is the kindthat just involves some symptoms
without any kind of severedistress or impairment to your
life, and I think our intern'sgoing to chime in here.
(06:01):
Treatment options include kindof just like watching it
psychotherapy, and just likedoing things that are good for
you, like exercise and doingthings that make you feel good.
Ed Delesky, MD (06:14):
Yeah, why don't you tell us a little bit about
moderate depression?
Nicole Aruffo, RN (06:17):
Moderate depression is when something is
involving some more symptoms,and then this is when one might
have some suicidal thoughts, andthis is the time when an
antidepressant medication mightcome into play.
And then severe is really whenyou're having all these symptoms
that are so severe that they'reinterfering with your ability
(06:39):
to function and like youreveryday life, and this could um
treatment could be acombination of the
antidepressant medications andpsychotherapy.
Ed Delesky, MD (06:49):
Yeah, and one other thing that you'll probably
come across if you go to seesee your doctor or someone who's
taking care of you is somethingcalled a PHQ-9.
It stands for patient healthquestionnaire and it is a set of
questions that are written on apiece of paper or on a computer
and you answer them yourselfand it's essentially a mood
(07:11):
screening and it's also used asa scale.
So the higher the score, theworse your symptoms are, and
it's a way that patients cancommunicate with their doctors
in a way that might be lessintimidating Sometimes if you're
in the quiet of your own headand then you can write these
answers down, you cancommunicate how you're feeling a
little bit easier than openlyadmitting that maybe you're
(07:33):
feeling all of these things, andso you can track those things
over time.
Like just this last week I wasable to say, hey, your score was
a 17 when we started talking amonth ago, and now that you've
been doing therapy it's an 11and you should really celebrate
that and take solace that whatyou're doing is working.
So that's the PHQ and that'sreally how usually we get to the
(07:55):
mild, moderate and severecategories.
Nicole Aruffo, RN (07:57):
All right, let's talk about those
medications.
Ed Delesky, MD (08:00):
So medication is a can be an extremely important
piece of the treatment plan formajor depressive disorder, and
so there is a large umbrella ofmedications called
antidepressants, and under thatname and title umbrella there
are several different classes.
The most common class ofantidepressant medication is
(08:22):
called a selective serotoninreuptake inhibitor.
There are several of thesemedicines, and there's very
commonly prescribed medicines aswell, and if you talk to a lot
of people that you know, I bet ahandful of them probably take
these, but maybe they're justnot advertising it.
And so these selectiveserotonin reuptake inhibitors
(08:43):
are abbreviated SSRI and they goby different names.
And so for a fair and balancedconversation, we'll give the
generic name and some brandnames.
Some names go by escitalopramor Lexapro is the brand name,
paroxetine or Paxil, citalopramor Celexa, fluoxetine or Prozac
(09:07):
and sertraline or Zoloft, andthese are all very common
medications.
As I said earlier, they work byinhibiting the reuptake, as the
name might suggest, ofserotonin at the synapse.
So when two nerves arecommunicating with each other in
the brain, these medicines makefor an increased amount of
(09:30):
serotonin between those twonerves to communicate.
Functionally, what they do isthey help people cope with their
situation.
They themselves do not dealwith the problems that someone
may have that may lead to themhaving depression we will talk
about the thing that does thatlater but they may make it
easier for people to react tothose situations, and so it's
(09:52):
something we're going to talk alittle bit more about some
details.
But to continue on, there arealso serotonin norepinephrine
reuptake inhibitors.
This is a similar medicine, butinstead of just increasing the
amount of serotonin, it alsoincreases the amount of
norepinephrine.
Some common names includevenlafaxine, otherwise known by
(10:14):
the name Effexor, and duloxetine, otherwise known by Cymbalta.
There are other older atypicalantidepressants and other
related meds, including thingslike tricyclic antidepressants
and monoamine oxidase inhibitors.
These medicines aren't ascommonly used anymore.
(10:35):
They still may be used inspecific situations, but those
specific medicines tend to havemore side effects like dry mouth
, constipation, dizziness andurinary retention.
For tricyclic antidepressantsand the monoamine oxidase
inhibitors or you may have heardof MAOI these require a lot of
(10:56):
dietary restrictions, in the waythat you literally need to
change the food you eat becausethey may interact with these
medicines, which make them alittle cumbersome.
One other medicine that's verycommonly used, that's a
norepinephrine and dopaminereuptake inhibitor, is called
bupropion, and that's a verycommon one, well used and
tolerated for people who havedepression.
So with so many options, therecomes a point where you need to
(11:17):
select a certain antidepressant,and for mild to moderate
depression, there is a consensusout there that SSRIs are the
first line treatment becausethey have similar benefit to the
other medicines and they havethe least amount of risk
associated with them, includinga lesser amount of risk for side
(11:38):
effects, which tends to be verypositive.
There are the reasonablealternatives that we already
discussed, and generally theyall have similar effectiveness.
When it comes down to itbecause even the SSRIs there is
a long list up there that I gaveyou there are several different
factors that eventually helpnarrow down which one someone
may end up on.
Safety and potential sideeffects.
(12:00):
Some of them have certain sideeffects that others don't, and
so maybe you end up leaning oneway or another.
Certain phenotypes orpresentations of depressive
symptoms may do better withcertain types of antidepressants
.
If someone has otherpsychiatric or medical
conditions, that may pushsomeone to prescribe one
(12:22):
antidepressant over another.
A potential for druginteractions.
How easy is this med to use?
Is it dosed once a day, twice aday?
Do you take it in the morning?
Do you take it at night Once aday, twice a day.
Do you take it in the morning?
Do you take it at night?
Some people have a familyhistory of a relative having
success on certain medicines.
That's taken into account.
Occasionally Cost and insurancecoverage become issues and
(12:50):
previous responses to priorantidepressants, and when you
consider all of those, moreoften than not you land on one
specific medicine that workswell for the person.
Nikki, I've done a lot oftalking here.
Can you take us through someside effects, knowing that for
SSRIs there are many less sideeffects, but we want to have a
balanced conversation here andrecognize that sometimes there
(13:11):
are.
And so what could someone belooking out for if they are
concerned about a side effectfor an SSRI?
Nicole Aruffo, RN (13:17):
So some side effects include sexual
dysfunction, some reports ofwaking, dry mouth and also some
insomnia, but typically thesesymptoms are most often mild and
they'll go away within about aweek or two.
Ed Delesky, MD (13:35):
Yeah, I've recently seen that people
sometimes will say like, oh, Itook the medicine once and I
didn't feel great, so I stopped,and I appreciate that they came
back and told me that like thishappened yesterday and I'm
really happy they came back andinvited me to be a part of that
conversation.
But, at the same time, thesemedicines can be very effective,
(13:56):
but they have to be usedcorrectly, and so, if you do
have questions about sideeffects, ask your specific
doctor, because each of thosemedicines may have slightly
different variations, but that'sa very broad overview.
When thinking about thesemedicines, dosing is something
important to consider.
A low dose minimizes sideeffects, but it's important to
(14:17):
make sure that you're followingyour doctor's instructions and
increasing that dose when theysay so, whether it be increasing
at one week or in a month,because really a lot of times,
because those dose adjustmentstend to be very important,
because, quite literally, themost common reason for people
failing these medicines arebecause the medicines are at low
(14:40):
doses or they are usedirregularly, and so if you rely
on your doctor or nurse who'staking care of you, they can
help guide you through thatprocess to get you at the right
dose at the right medicine forthe treatment that you're
undergoing.
Nikki, these medicines have alot of conversation, like I
mentioned, that lady yesterday Isaw who said I took it one time
(15:03):
it didn't really work.
Tell us a little bit about thetimeframe, about how these
medicines work.
Nicole Aruffo, RN (15:08):
So it will take some time for these meds to
start working fully.
A lot of people will start tofeel better within maybe as
little as a week or two, butreally you have to give it a
solid six weeks beforedetermining if this medication
is actually making you feelbetter and working for you this
is such a common thing like I'llsee someone, I mean that's a
(15:30):
long time that is a long time sothat can be frustrating, and I
see why people wouldn't want tokeep taking it, you know.
Ed Delesky, MD (15:37):
Yeah, one thing I do worry about is to that
earlier point where if peopleare taking, let's say, they're
at six weeks, but they've beenat the lowest dose of Lexapro
and I worry that they'll losefaith in the treatment plan when
there are like two more stepsabove that before they actually
get to the treatment dose.
And so, specifically, this issix weeks at the treatment dose,
(16:00):
not at the starting dose, tosee if you tolerate the medicine
.
So that's an important bit.
And what other thoughts do youhave about that?
None, and I hear you.
I think that that can be atough thing for people to
appreciate, because there aremedicines that make you feel
different immediately, likespecific anti-anxiety medicines.
(16:23):
You take them and then inminutes you feel less anxious.
But this is the long run.
This is almost like a vitaminfor your mind, and so it's an
important part of the treatmentplan, but it ends up not being
everything.
Usually, when I'm with someonewho's getting the depression
talk from me I draw them atriangle and I draw them on.
(16:44):
One arm of the triangle ismedication, the next arm is
therapy and the third arm isbehavioral activation.
Let's talk about the second arm, let's talk about therapy.
So when I draw that triangle.
I really try to emphasize andsay that all parts of treatment
end up making for the mosteffective treatment of your mood
(17:05):
disorder.
In this case we're talkingabout depression.
Evidence will suggest thatPsychotherapy, and specifically
cognitive behavioral therapy,and medication are just as
effective as one another.
But there's also apreponderance of evidence that
suggests that if you use both atthe same time, you will have an
(17:27):
even more effective treatmentplan.
And so there are multiple typesof therapy.
There are multiple types oftherapy.
It is not just like you'resitting on a couch with someone
who has elbow pads and amustache, divulging your life
secrets to this person.
There are many different typesand we will define them here.
There is cognitive behavioraltherapy, or CBT.
(17:49):
This type of therapy identifiesand reshapes thought and
behavior patterns.
So let's see.
One example of this would besomeone who has a one-time
herpes breakout and they, forone year, are terrified of
engaging in a relationship withsomeone because they are so
(18:12):
worried that they will pass italong to someone else.
They've never had anotherbreakout.
The risk is relatively low, butthey will not engage with
another person.
They won't even talk to someonethat they're interested in
because they are so terrified ofthe possibility of giving
someone else herpes, and so onemight suggest that that is a
(18:34):
thought pattern that could bereshaped through cognitive
behavioral therapy.
There is interpersonalpsychotherapy.
I see this less frequently.
This focuses on relationshipsand interactions with others.
There is family, and manypeople have heard of this
couples therapy.
These address issuescontributing to depression and
(18:55):
family members or partners.
There is something calledproblem solving therapy, which
uses a systematic approach tosolve practical problems, and
there is psychodynamicpsychotherapy, and that is the
armchair sitting back with theelbow pads, with the person with
the mustache, because that isexploring past life events to
(19:17):
understand current behavior.
So that was a lot and somethingreally practical that we wanted
to share on this episode isselecting psychotherapy, or how
the heck do you get into therapyis the question, and so one
easy point of access could beasking your primary care doctor.
Many primary care doctors havebehavioral health consultants
(19:40):
that they work with or that theycould refer you to, and that is
a great access point.
So first stop your primary caredoctor.
The second stop is somethingthat I usually say every time
I'm having a conversation withsomeone, and you can literally
hop off of this episode afteryou listen to the full thing and
after, you share with a lovedone or a neighbor and you can go
(20:01):
to this website.
It's called psychologytodaycomand on this website you are able
to see a breakdown oftherapists.
You are able to see theircredentials, areas of special
training, their mantra, theinsurance coverage they take.
You can see what they look like, you can see do they do online
(20:21):
or in person, and in that wayyou can break down and find
someone that's in your area,that you might be most
comfortable with, accessible,affordable, and that you can be
proactive in that next step andengage in your treatment more so
.
Once again, that ispsychologytodaycom and it is
available to you right on yourphone, where you're probably
(20:43):
listening to us right now, andso those are two options to get
access as soon as either yournext appointment or today See
your PCP or psychologytodaycom.
One comment to say about now.
We've talked about twodifferent arms of the treatment.
We've talked about takingmedicines and we've talked about
therapy.
We've talked about how theyusually work better together,
(21:05):
and when you go to therapy, youtend to work through some of
these problematic thoughts thatmay be sticking around, causing
certain your symptom pattern.
Usually, it seems like therapytends to last longer because
you're getting to the root ofthe problem, but SSRIs can be
very helpful for those whosimply need them, and it's a
(21:28):
very important arm of treatment.
So I think the audience hasbeen hearing my voice so much in
this episode.
We've talked about if I drawthis triangle.
We've now talked aboutmedications, we've talked about
psychotherapy, but let's talkabout behavioral activation and
other aspects of treatment fordepression.
(21:49):
Take us through exercise.
Why is exercise so importantfor depression?
Nicole Aruffo, RN (21:55):
well, when you exercise, you get endorphins
, and endorphins make you happy,and happy people don't kill
their husbands.
Did you just come up with thaton the spot or is that?
No, it's from legally blonde.
Yeah, when the um like exerciseinstructor was on trial for
killing her husband oh my god,and then that's.
(22:17):
That was like elwood's defense,but then she was right.
It turns out that the daughterkilled him, but she thought that
it was the stepmom exerciseinstructor this has to do with
the perm right, it was juicy.
Yeah, yeah, I remember this,yeah um, yeah, so that's the
basis of that.
That exercise makes you feelgood, and because it makes you
(22:38):
feel so good, it's suggested tohave 30 to 60 minutes of heart
rate increasing exercise atleast three times per week.
Ed Delesky, MD (22:46):
And what about people who maybe aren't
exercising so frequently?
Nicole Aruffo, RN (22:50):
So that's just suggesting starting off
with more gentle activities likewalking.
You can take your dog for awalk.
Do some work around the houseand the garden.
You can do something, beproductive and active at the
same time.
You'll feel great.
Ed Delesky, MD (23:08):
Exactly, and I really would like to emphasize
this point because this issomething that, if you're
listening to this and you'relike I actually I do have
depression you can get out theretoday and this isn't just
something like, oh, I shouldexercise.
When you look at it in theframework of this is a treatment
plan.
This becomes a part of yourprescription and so now it's
non-negotiable, like if you wereto take a medicine every day.
(23:30):
If you have high cholesterol,you have increased risk of heart
attack and stroke.
You would probably take yourstatin.
If you had high blood pressure,you would watch how much salt
you have in your diet.
You would probably take yourblood pressure medicine.
If you have depression, you'reprobably thinking about taking
your antidepressant.
Finding and engaging in therapy.
Exercise becomes a part of yourprescription plan, and you
(23:53):
almost have to force yourself todo this.
If you're sitting at home, notdoing anything, ruminating in,
frankly, sadness, that won'thelp.
So as a part of yourprescription plan, you have to
engage in some sort of exercise,whatever it may look like.
This goes along with behavioralactivation.
(24:13):
Behavioral activation is aresumption of enjoyable
(24:33):
activities that were because ofthe depression.
Maybe you like to read and maybeyou stopped reading because of
the depression.
Perhaps you did yoga.
Maybe you get back to doingyour yoga or go on walks,
whatever that thing is.
Take a long moment and reflectwhat could I do that I used to
(24:54):
like to do, and then makeyourself do it.
This is so much easier saidthan done.
There are huge motivation andconcentration components to
depression and its pathology,but this is the point is that in
that triangle of treatment,you're getting out there and you
start doing those things thatyou once liked to do because
(25:15):
it's important and it will helpyou.
Is that easier said than done?
You think?
Nicole Aruffo, RN (25:20):
Yeah, probably.
Ed Delesky, MD (25:21):
And so, as we're wrapping up this episode here,
I really want to highlight thatthere is hope and there are
plenty of opportunities to beable to help yourself, even as
soon as you're done logging offthis episode, to treat
depression, if that's somethingyou're dealing with, also
several other mental healthdisorders, and so think of that
triangle the next time thatyou're considering how well are
(25:42):
you doing?
Are you taking medicine?
Have you thought about medicine?
Is that an option for you?
Have you engaged in therapy?
And how well are you doing onbehavioral activation and
exercise?
And if you work closely withyour doctor, you should be able
to see some improvement.
And if not, then keep going,keep trying to get help, because
(26:04):
there is hope for recovery outthere and feeling better from
what is a really common, reallyimportant illness to consider.
So thank you for coming back toanother episode of your Checkup
.
Hopefully you were able tolearn something for yourself, a
loved one or A depressedneighbor.
(26:24):
Please check out our Instagram,our website, send us an email
yourcheckuppod@gmail.
com.
Send us some fan mail and, mostimportantly, stay healthy, my
friends, until next time.
I'm Ed Delesky.
I'm Nicole Aruffo.
Thank you and goodbye, bye, bye.
This information may provide abrief overview of diagnosis,
(26:48):
treatment and medications.
It's not exhaustive and is atool to help you understand
potential options about yourhealth.
It doesn't cover all detailsabout conditions, treatments or
medications for a specificperson.
Thank you given or its use.
This content doesn't endorseany treatments or medications
for a specific patient.
Always talk to your healthcareprovider for complete
(27:18):
information tailored to you.
In short, I'm not your doctor,I am not your nurse, and make
sure you go get your own checkupwith your own personal doctor.
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