Watching: TAKE ONE STEP: Caring for Depression, with Jane Pauley
Chapter 2: A Medical Disorder [7:13]
What are the biological elements of depression? How do you recognize and treat depression in children?
Transcript: Chapter 2 - A Medical Disorder
JANE PAULEY: A message that was repeated throughout the 90-minute documentary and that I repeated in our introduction was that depression is a medical disease. That was not always obvious. But now it is a fact. But what do we mean by that? What is, as a scientist, what is meant by, it's a medical disease?
DR. DENNIS CHARNEY: What that means is that we've been able to uncover, what are the biologic causes of the condition. So, for example, as I've mentioned, that there is a genetic basis to many forms of depression. That means that your genes are making certain chemicals in your brain that make you vulnerable to depression. In addition with advances in our ability to look inside the brain with brain imaging techniques, scientists have uncovered specific parts of the brain that don't function normally in patients with depression and bipolar disorder. So it's that kind of information that leads us to say really without a doubt, uh, that depression is a medical disorder.
JANE PAULEY: That said, depression isn't a disease. It's a number of different diseases. Do I say that right? And what do you mean by that, Dr. Charney?
DR. DENNIS CHARNEY: That's correct. There are some forms of depression that start early in life, like in children. That is a different disease than depression when it starts for the first time at age 65. The biology is different. The causes are different. Another example is depression that's associated with being postpartum. So depression is not one disease. It's at least several diseases, with a different cause.
JANE PAULEY: Dr. Duckworth, when you see a patient in a, in some clinical setting, does it matter whether they believe that their depression is a medical disorder or something else?
DR. KEN DUCKWORTH: Well, I think it's a great question because how people conceptualize the process of depression and bipolar illness is relevant to whether they seek help or not. Mood disorders run in my family. And I can say that's the reason I've become a psychiatrist. And I can say, people in my experience, both clinically and when I was a kid, who are able to accept their illness as an illness like heart disease, or even other processes in the brain which we all seem to be able to accept - strokes, Alzheimer's disease-- these are kind of uncontested medical phenomena. But the clinical idea of a depression or bipolar illness somehow challenges people.
And I think part of that is because people have experiences of having bad days and getting over it. And the personal pride of just wishing, you could will yourself through it-- But this of course can be quite counterproductive given the number of disability days lost with things like depression, uh, the risk of suicide, and some of the other problems that travel with it, people using substances in the hopes that that will change how they feel, which can lead to some very catastrophic outcomes.
JANE PAULEY: I do hope that, you know, anybody listening and thinking, "Am I okay?" will go find out, you know, that that first step will be a phone call to, a friend, a relative, a doctor, a somebody to find out.
You volunteered that depression runs in your family. As far as I know, it didn't run in my family because there wasn't any vivid history. But when you think about it, sometimes family history is family secrets.
Let's talk about kids. If change, as Dr. Primm said, is the underlying commonality among symptoms, if you're looking at a child-- in our documentary, Emma was in the fifth grade and Hart was in the sixth grade when their symptoms first began to be apparent. In children, change is every day. Every day you change. So how does-- How do you as a professional or a parent or a teacher recognize depression in a child?
DR. KEN DUCKWORTH: Change is the watchword of childhood. And it's a beautiful thing. And Hart and Emma, I think, are compelling, likeable kids from very well functioning family systems.
But they were experiencing something that was two or three standard deviations different than what their peers were experiencing. And they knew it, at some human level. They'd lost interest in things. Hart was struggling with suicidality. And I think to make the diagnosis isn't that easy. But one of the pieces you're looking for, has is the child changed from how you knew him? There are also clinical symptoms that travel with it, sleep changes, physical complaints. Kids tend to be more irritable or hostile, um, as opposed to just straight up sad in the context of mood changes. And I would say to parents, if you're waking up at 4:00 o'clock in the morning worrying about your child, you might want to consider getting an evaluation. 'Cause in my experience, the parents know the children well.
JANE PAULEY: Back to Hart, who was diagnosed with bipolar. That's a very special complication. Bipolar depression is an entirely different beast. But it's risky diagnosing a child with depression as in Hart's case, because if you treat it as unipolar depression, and this is my life story here, if you treat it as unipolar depression, prescribe medication accordingly, not recognizing bipolar, you've got yourself a catastrophe.
DR. KEN DUCKWORTH: This can be a real potential pitfall for clinicians and families alike, that if a child has an oscillating mood syndrome, if the first thing you catch is the syndrome of depression coming down, you haven't been able to watch the whole movie yet. The movie hasn't been run. You're seeing the frames that illustrate depression. But the child could have a vulnerability for bipolar illness.
It's particularly important to look at the family history. If there's a family history of bipolar illness, be very mindful of that. And I also encourage people to stay humble. Because diagnosis changes over time as kids through developmental stages, different developmental stages. Say, "At this point in time, this looks like depression. And you could be at risk," you know, "...for bipolar illness because this runs in your family." So we need to be mindful about that.
And then also illustrates the point of not just relying on the medication. Psychotherapy, counseling, substance abuse work, building on a person's strengths, in Hart's case, changing schools, going to a different kind of environment, that there's a lot of ways to try to solve this puzzle. There's a lot of tools in the toolbox. But I think a more comprehensive view with more monitoring and humility, not knowing, that the story hasn't been told when the child's fourteen.
JANE PAULEY: (Do you know, we know about...)
DR. DENNIS CHARNEY: Just to maybe make one point here.
JANE PAULEY: Please.
DR. DENNIS CHARNEY: It's critical to ultimately getting the diagnoses to be accurate--
DR. KEN DUCKWORTH: That's right.
DR. DENNIS CHARNEY: --because if you give a child or an adult an antidepressant medicine and they have bipolar disorder and you have not given another medicine to control the mood swings, you can induce a manic reaction. And that's where the catastrophe can come in.
JANE PAULEY: That's what happened to me.
DR. DENNIS CHARNEY: Yeah. So, you really have to, you know, work as hard as you can in ruling out bipolar before you start an antidepressant medicine [simultaneous conversation]--
DR. KEN DUCKWORTH: And you have to always think about it. Always-- always think about that possibility. 'Cause depression is more common, but bipolar illness is quite severe.
JANE PAULEY: I may be unique. I don't know what percentage of patients are as actively motivated to mind their health as I am. I certainly will never be the patient in denial. I will not be the patient who is not compliant with, you know, prescription. And not being compliant is a huge problem, isn't it?
DR. KEN DUCKWORTH: Yeah. And that's also very human, but it has to be dealt with. Everybody wants to know, every teenager that I've worked with wants to conduct the experiment, is, "Do I need any of this? Do I need to come see you, doctor? Do I need to take a medicine? Do I need to participate in substance abuse treatment?" It's very human to want to run the experiment. "Can I do without it?" Right? "Maybe I can just forget all this stuff and see if it goes away."
But of course that is not a great strategy, given the amount of suffering and bad outcomes that can occur. So I just encourage people to really look at the potential risks of not participating, not complying with treatment, but also understanding that at different parts in a person's life, many people, unlike you, are gonna try a period of time without it. And I just say, "Let's see if we can learn from that." Because if you can learn from that, the rest of your life, you can use that information for good.
DR. DENNIS CHARNEY: That's a factor. And also if you abruptly stop your medicine, it can send you into a worse episode. So even when doctors decide that it is time for a drug holiday or to see if you still need your medicine, you can't stop it abruptly. You have to, you know, go slow as you come off your medicine, and observe things very carefully.
DR. KEN DUCKWORTH: It's a really important point. It's like airplanes. You know, when they're gonna land in Los Angeles, they start going down over Chicago. Think of your medicines like that. Don't do abrupt things to your nervous system.
JANE PAULEY: --ever.
Jiwe--- a study in trauma and resilience. You know, god bless him. You kind of see, there-- it will be a happy outcome to that story. But go figure, you know, a kid with his background in gangs and violence and drugs, resists drug therapy. Why would that be? Is there a rational explanation for that?
DR. ANNELLE PRIMM: Well, it's very common, particularly among young people and among men and among African-Americans not to want medication. They don't want to feel as if they're using a crutch, that medicine is a crutch. And, really subscribing to a more-- a stoic approach. They may accept counseling, of course, but really the medication just represents something that they don't want to be associated with, and really increases the stigma surrounding treatment.