Video & Transcript for Class Colloquium 13: Depression

Here is the video of Jerry’s talk and Q&A.

The “chat” function captured these points and questions:

11:58:20 From Jeff Wheelwright to Everyone:
Serious question, lightly put: How have you not managed to become depressed yourself, considering the lack of progress in treatments of serious depression? The grab for psychedelics is a sign of desperation in the field, IMHO.

12:03:48 From Richard Huttner to Everyone:
Could you talk more about ECT. Thanks

12:03:55 From Jonathan Hoffman to Everyone:
This chat session involves mostly folks who have the means to use psychiatric/therapeutic treatment. Are there ways that poor and working-class people can partake of treatment?

12:04:28 From Robert Pollack to Everyone:
Comments on TMS TBS and Ketamine

12:06:23 From Tim Weiskel to Everyone:
Or take, for example, the news this morning about Chernobyl…”Ukraine war: Chernobyl power supply cut off, says energy operator – BBC News,” https://environmentaljusticetv.wordpress.com/2022/03/09/ukraine-war-chernobyl-power-supply-cut-off-says-energy-operator-bbc-news/

12:09:42 From David Feigenbaum to Everyone:
Make an educated guess on the likelihood that the prevalence of depression in members of our class of 69 mirrors (will mirror) the prevalence in the general population.

12:11:55 From Tim Weiskel to Everyone:
What is the link — if any — between diet and depression over time?

12:12:31 From Tom Weber to Everyone:
Depressive people seem to spiral down, sometimes to the point of refusing help. How does one get someone into one of the several treatments available? Are there strategies?

12:13:22 From Tom Reed to Everyone:
Can you speak to the impact of the extended isolation that the pandemic has imposed on many? For example, some say the 1918 Spanish Flu led in some ways to the Roaring Twenties. Tom Reed

12:14:31 From Jamie Woolery to Everyone:
I wanted to express my gratitude for Dr Rosenbaum for his excellent talk

12:22:51 From Jamie Woolery to Everyone:
So the Stanford program passes the Turing test?

12:23:40 From Steve Bemis to Everyone:
I’m aware of two patients (the only two in my sample universe) for whom ECT was indeed dramatically effective. In one case, unfortunately, after 20+ years of recovery, a gradual relapse was not followed by additional treatment due to the patient’s internist’s lack of interest in helping his then-elderly patient.

12:24:52 From Jeff Wheelwright to Everyone:
Sorry to be the contrarian again…ECT is almost 100 years old. Lithium at least 50 years old. Those two treatments have not been superseded by any better ones for resistant disease. The plethora of new drugs do not constitute an advance, just spinning of wheels. Most people with depression will recover over time without any treatment whatsoever. I have been a patient, I should add.

12:33:14 From Jonathan Hoffman to Everyone:
Thanks, Jerry, and au revoir to my beloved classmates. Very relevant and stimulating.

12:34:11 From Tim Weiskel to Everyone:
Thanks, Jerry, Tim Weiskel

12:34:48 From David Lohman to Everyone:
Thanks, Jerry and all who set this up. Leaving now.

12:36:06 From Rick drost to Everyone:
Thanks all. I’ll get a run in before it snows.

We turned on the closed captioning part the way through:

[Note:  The “speech to text” software clearly mis-transcribed many of the sentences below, so be careful.  If someone is up for listening to the recording and cleaning this up, I’d love that.  Let me know, and I’ll set you up.  –  Wayne Willis, support@Yale1969.org.]

[Note 2: We started in the middle of Jerry’s talk, so the first several minutes was missing.]

Art Segal:
Could you talk a little about the side effects of antidepressants, and specifically, do antidepressants ever lead to manic behavior in your experience?

Jerry Rosenbaum:
Yeah. So they’re all the antidepressants have side effects, and they they vary somewhat based on their specific mechanisms of action. You know some are sedating, some can cause that agile, some cause nausea. Many of them cause sexual dysfunction, but not all. So some of the artists psycho farm is prescribing an antidepressant and making a rapid assessment of whether this particular agent is being tolerated by the individual because they’re all alternatives so there are medicines like the Ssris that i’d say two-thirds of people who start them can get on them. And about a third will have side effects that are limiting, usually a nausea or insomnia agitation. Some of those people, if you lower the dose, get through it, and they and they accommodate to, and they go away. But over time other side effects emerge like sexual dysfunction, which is used delayed orgasm, which has actually led to the Ssris being used for premature ejaculation. But for other people that’s challenging so they do have side effects, and they can be limiting for some people. But a medicine like the appropriate or well-known, does not have those side effects has other side effects. It’s you know can cause anxiety in some people, but it doesn’t cause sexual dysfunction. Sometimes, when you combine antidepressants, you get a better at outcome and fewer side effects. So you you know. Sometimes side effects are offsetting, so we can combine something like the appropriate on Wellberryon with an ssri. You may get fewer sexual side effects, or merteza, pain which is a remareron which is an antidepressant that many people find too sedating and is associating with weight gain. You combine it with an Ssri. Sometimes you get less sedation and less weight gain, and you diminish the nausea with an Ss right? So side effects are a challenge. they’re part of the art of prescribing.

There are some fortunate people who experience very little denun and others who just can’t tolerate them fortunately. You know there are often alternatives, I mean, I mentioned, you know, psychotherapies and different pharmacotherapies that that may be tolerated better by one person than another. The side effects are very much limiting mania with and I mentioned there’s a there’s a mood disorder called bipolar disorder. It used to be called manic depression. disorder, manic depression, disease is. It is all the less common than major Depressive Disorder is you know. Still you know about 2% of the population and when you’re treating a depression for the first time. you don’t know whether that’s a bipolar depression, unless you have access to other information like past history of a manic episode, or hypermanic episode, or a family history of by polar disorder. So when you treat that depression, you may be treating it as what we call unipolar depression or major depression. But if it’s bipolar depression you’re what you ask is correct, that an antidepressant has been associated with an increased risk of switching into mania, so if you suspect that somebody’s bipolar, and they have a severe depression and you’re inclined to use an antidepressant. Many experts actually cautioned against that. others are comfortable using it, but only in the presence of a mood stabilizer. So like lithium, or some of the second generation. antipyotics, or certain anti-convulsants if they’re on board to help prevent the manic switch. Many people are comfortable using trying to use an antidepressant to encourage response. But there, there’s controversy about that about how useful our standard antidepressants are with bipolar depression.

John O’Leary:
What is the link, if any, between diet and depression over time?

Jerry Rosenbaum:
So there, there is a a link but it’s it’s it’s a little bit murky, and it comes back to the theme of inflammation. So there’s some evidence that if you are using an inflammatory diet. He has opposed to say, a mediterranean diet, and you eat a lot of red meat and and empty calories that you’re increasing your inflammatory state. And that may be the reason why that seems associated with increased risk of depression, and why some people who change their nutritional approach get some improvement. So it’s probably more related to inflammation although it may be more complicated than that, because when people are depressed, you do see changes in metabolism, and including the activity of insulin and glucose sensitivity, so people with depression their diabetes can worsen. For example. so there is a there is a link there between metabolic status, diet, and and depression. But it’s it devolves simply to the recommendation that I give all my patience is, if they can, to move to a Mediterranean diet or a non-inflammatory dry diet with less empty carbohydrates and red meats, and so forth, eating more fish. Fish oil has been. Don’t eat as a potential treatment for some people with the depression as well. and then, although the data is mixed, it probably is a reasonable thing to add,

Richard Hunter:
Could you comment on the effectiveness of ECT?

Jerry Rosenbaum:
ECT is is really life-saving and an extraordinary treatment. But it’s not perfect.

Unknown:
what is ECT please?

Jerry Rosenbaum:
that’s inducing a seizure using electricity or electoral convulsive therapy, where an individual who is brought into a recovery room, or not a treatment room. they’re given along with anesthesia so you actually don’t see anything but a electrodes are applied to the head that that spark a a seizure that is recorded but not observed and that’s that’s a treatment that goes back, as far as the 19 thirtys when, when when the observation that depressed epileptics often felt better after their seizures. But it, it is often a it’s considered a treatment for treatment resistant depression. So people who have not responded to all the different things we’ve talked about about two-thirds to 3 over 4 of them will have a dramatic response to ECT. That said it. You know you are getting Anna seizure. There are some risks people are will have some transit memory loss for the time around their procedure, and people with compromised brain function or elders, if they have too much ECT. The the memory effects may be more profound than that so ideally somebody gets between 6 and 12. treatments over a 2 to 4 week period, and that’s often associated with dramatic response, and people who have been suffering the way when you see it. most dramatically effective is being an inpatient unit with somebody who’s really failing to thrive, they’re dying of depression. They don’t eat. They don’t move and they simply wake up, and they’re well again. The challenge there, which is different from pharmacotherapy. Somebody responds to pharmacotherapy, they can stay on it, and that helps prevent relapse. Recovery from ect just gets you into a state of recovery. It doesn’t prevent the next episode and so you’re vulnerable to relapse. So then the challenge after you respond to ect is, how do you stay? Well, and some cases starting a a drug treatment then may work for the first time. Now that you’re in a recovered condition, where it didn’t work when you were ill in other cases, people go on to do what’s called maintenance ect where you may get a treatment a week, or a treatment a month or cheap it every 3 months, depending on how long you’re recovery, or your remission lasts between treatments. You know there are there when you have severe depression. If you’ve ever seen somebody with very severe depression if you are impressed and grateful for the Pc Team. We actually do brain implants, for people with severe depression, or what’s called deep brain stimulation, where electrodes are inserted into nodes, and neural circuits and and attached to a stimulator and and and people will have a constant brain stimulation that keeps them from being depressed. So it it’s and that is very what it works is very dramatic as well. But obviously that’s not something you do lightly and it’s with somebody who has exhausted all other possibilities. And you can’t bear their suffering most of these therapeutic interventions really are tattered to people who have insurance, or who otherwise well off.

Wayne Willis:
How about poor people and uninsured people with limited access to medical care?

Jerry Rosenbaum:
Yeah, I mean it will I mean that’s a that’s a huge, particularly current problem is access. I mean even people with insurance can’t get access in many cases. And in poor communities, and even those who have Medicare or Medicaid.
There may not be facilities or access, and so forth. Our hospital on the one hand, treats all comers, without regard to Deleted Bay, and it’s a very large department with hundreds of psychiatrists and psychologists who and has many specialized programs and nonetheless. our wait lists are, you know, months. So it accesses a huge problem, and it’s amplified in in urban populations, in populations, in in minority populations. And and you know the President is you know sort of made reference to the need. It’s so challenging I don’t you know we don’t have enough psychiatrists. You don’t have enough psychologists it’s it’s spawning a whole new industry of remote care and and treatment by applications, and either you can get psychotherapy. Now that looks to be fairly effective and there’s no human involved it’s all AI a group in Stanford has a company. Now that I wish I could give you the name of it I don’t have it right now where and and you can try it. I mean they let you try it for free and you have a conversation virtually, and it’s really extraordinary. You can’t tell that you’re not talking to a person so that you know the apps and remote access, and you know, and and monitoring devices are all probably going to play some part in in in covering for our lack of resources to treat people.

Robert Pollock:
I wonder if you can comment about TMS, TBS and Ketamine.

Jerry Rosenbaum:
A lot of going on for the last years. So one thing you need to know is that there is. There is lots of a new, not just the psychedelics but other novel treatments that work by mechanisms that are quite different than anything we’ve used before that do work and help people who aren’t helped by other things so one is the observation by colleagues at Yale. That an old anesthetic drug, which is also had, has been abused as a party drug called ketamine, and in low doses. But initially by infusion. can dramatically relieve depression almost like ect, and in an interesting observation. Some people who didn’t respond to ketamine for their depression. There’s suicidal ideation there’s suicidality went away. So it seems like an anti-suicide drug, and also a rapid treatment. Yeah, you got one infusion to 2 or 3 infusions a week over a couple of weeks is very effective in treating depression. Black ect. It’s going. The dilemma with ketamine is not that it’s effective and clearly is effective. Is that, you know it’s not always durable so people will relapse, and, like with other treatments, may require maintenance treatments, or in some cases stop responding. One form of suitable company. came up with a form of ketamine. What an enantiomer it’s a racemic drug! So the single enantiomer called eschetamine, which they deliver enter nasally In a drug called spavato, unfortunately kind of expensive and and hard to access, but also works not quite as effectively as the infusion, the intravenous infusion, but can work. And if you have a well-. informed psychopharmacologist in your neighborhood, they can actually simply buy generic ketamine, which is about 10 bucks for a while, and have a compounding pharmacy make a nebulaizer that would give you you know months worth of treatment that that you can use to spray it. You need somebody who knows what they’re doing. So Ketamine is very dramatically effective.

Bob also mentioned trans cranial magnetic stimulation, which is interesting and basically a magnet that creates an electrical field is quite selectively, ideally based on imaging data that help people isolate you know, where in your brain an important node and neural. circuit is that’s associating with depression, and that will induce a current that that causes electrical stimulation. But it’s asymptomatic you don’t feel it. All you feel is this device touching your head, and that treatment, Tms is also associated with relief of depression. They’re new forms of it emerging that that are more precise. There’s something called fader bursts which allow one to give intensive tms in a short period of time. Otherwise it’s a daily treatment for an Hour over several weeks with a new form of it called Theadorus, can be given in one week, and that’s also in our experience and day, and the data supported that it can treat people who have not responded to drug treatment. psychotherapy or other treatments and is preferable to ect because there’s no anesthesia, no headache, no after effect no recovery. It’s it’s much more acceptable so train tms or transcranial magnetic stimulation Again, what were you? What you’re hearing is that a dilemma that there is all these treatments, all of which work for some people. It’s the matching it’s the it’s the getting the person to the thing. They can respond to earlier this. so-called precision psychiatry, that is our challenge now, because it makes for some people months and months of trying different things before they get to tms and tms works with them and they’ve been it. Could there have been a way that we would have predicted that early, so they would have avoided all that additional suffering, time, and effort.

Art Segal:
And you make comments about depression in the elderly.

Jerry Rosenbaum:
Those modification, sensitivity to better treatments are better, which are worse than, and our cohort of people. So there are 2 issues. there. One is somebody who has depression and happens to get old. How does that? How does their depression treatment have to change? And and you really are hinted at. One of the issues is that you know we elders are more sensitive to medications are, are more vulnerable to side effects, and some of the drugs affect heart rhythm for example, so you have to be more vigilant about the medical consequences of some of the drugs, and be more careful with dosing and side effects. But if but the mistake that sometimes results from that is that you undertreat an elder whom might respond to a more standard treatment, the other side of it, is there are individuals who develop depression for the first time late in life, and that’s undoubtedly linked to all the other changes. Consequent to aging you. You know. you see, changes in brain structure. You see, increased indications of vascular changes that undoubtedly contribute to risk for depression anything that interferes with your capacity to think, feel, and behave your cognition your ability to handle stress, the resilience of your brain will influence and increase your risk of depression, and that, unfortunately, is something true. As as we get older, and some of the non-pharmacologic treatments, like ect, are particularly helpful in severe depression and elders.

Unknown:
People seem to spiral down sometimes to the point of refusing help. How does How do you get one into one of the several treatments available? Are there any particular strategies that you have? Yeah.

Jerry Rosenbaum:
So the I mean they’re different they’re there’s certainly people who refuse help, and it’s a dilemma. Yeah. because even when we believe there are treatments that can be helpful and less, somebody Is a eligible if that’s the right word to have to be treated involuntarily, which means that they’re deemed to be a risk to them usually in most States to a risk to themselves or others are unable to care for themselves. you can’t you can’t make people get it. Get a treatment that’s one of my colleagues a forensic psychiatrist says people are given the right given the ability to die with their rights on. So they’re the issue is not giving up it’s not saying, Okay, it’s his choice. It’s not really his choice if he’s depressed unless you know that this is a cantankerous person who refused care for anything, you know even his heart disease or something. But if it’s the depression speaking, and they’re pessimistic, and they don’t believe they can be helped, or they’re not worthy of health, they then it becomes a team effort. You know, loved ones physicians. Everybody just has to keep on it. You know people do interventions for depression as they do with substance. Use disorders where family members you know come in and say Dad, you know we love you. You’ve got to do this for us you don’t have to commit to anything. Just go talk to this guy, and if a woman and enough that conversation can be supportive and understanding. You can get people to give you something. So you know. let’s let’s just do this sale you sleep, or let’s talk some more let’s agree to talk some more. Let’s agree that if you start to have these thoughts you’ll call me and you sort of work your way towards a treatment again.

The dilemma is it’s a journey sometimes and you hope that this person might be one of those lucky one and 3. You do real well with whatever you pick first but they have to understand that’s a long-term effort, and you’re with them, and you’re not going to force them to do anything you don’t want but you’re on their side. it’s an art and it’s a challenge, and sometimes you you lose art aren’t single are you are you with us.

Art Segal:
Jerry, I want to thank you sincerely for a enlightening all of us on a subject that is pervasive around us. And yet needs better understanding. It’s obviously a pervasive but a tricky problem to affect improvements. So I thank you for your willingness to teach us all, and I thank you for your willingness to to, and one of the breakout groups where anybody else wanted to ask any further questions that may not have been asked. Can do that in perhaps a slightly more private setting, with less people listing. If that’s important to the remainder of the people will be offered. One of our typical breakout groups, so that you can socialize a little bit if you wish. Wing will get that set up, and we will announce online when our next sessions are apologies for my technical issues. Today want to thank you sincerely jerry that was a wonderful overview with specific in depth. Looks at at various elements of depression, and we couldn’t help it. Come away. better served and better informed thank you thank you It’s nice to see a lot of old friends. guys.

Wayne Willis
Okay, we’re going to use this new zoom feature, where you get to choose your room, and so if you want to join Jerry in the depression part 2 just choose that room, and if you want to just visit with each other and see who else around, say hi! And so on. Choose the other room.

[broke into 2 breakout rooms]