Major depressive disorder (MDD) is one of the most common mental health conditions. It can affect all aspects of life, from everyday activities to major milestones.
In a WebMD Reddit AMA about living with depression, psychiatrist Marcus Hughes, MD, discussed a variety of topics, from screen time and its effects on symptoms to treatment affordability.
Hughes, an assistant professor at Yale School of Medicine in New Haven, Connecticut, has expertise in treatment-resistant depression and specializes in new and upcoming treatments.
Here are some of the questions asked during the Reddit AMA and Hughes’ answers.
How do you treat depression when it’s due to circumstances in life that are difficult or impossible to change, like chronic health issues?
Hughes: A holistic approach to the treatment of depression is often needed and will best set folks up for success. Medications and other biological treatments are often helpful, though they may offer limited symptom relief. So it’s important to include psychotherapeutic interventions as well as lifestyle and medical interventions when discussing a treatment plan.
Social support is often overlooked. It’s important to encourage and help folks to find community and meaningful experiences that may provide symptom reduction and fulfillment. Oftentimes, we may expect some level of depressive symptoms to remain in the face of chronic stress. In those cases, the focus may shift to finding an acceptable level of functioning and helping folks reframe treatment and wellness goals.
What’s the best treatment approach for anhedonia?
Hughes: Anhedonia is a difficult symptom to treat and often lingers even when other symptoms have improved with treatment. Good approaches include behavioral activation and reward-focused psychotherapies. Dopaminergic-modulating drugs (e.g. stimulants, bupropion) can be helpful as anhedonia is related to deficits in the reward system, in which dopamine plays a large role.
This is a hot area of research and many drugs are being investigated to target anhedonia. Relevant to current times, stimulation from screens can cause large dopamine spikes and make more mundane tasks such as eating, bathing, socializing, etc. less appealing. I often suggest to folks to decrease their screen time and to engage in activities that involve delayed gratification.
What are the treatment options for folks who don’t seem to respond to treatments and remain severely depressed and suicidal for years?
Hughes: Many treatments for folks whom we deem treatment-resistant exist, such as various neuromodulation approaches (e.g., electroconvulsive therapy, transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, etc.) or novel treatment paradigms like psychedelic or ketamine-assisted therapies.
Unfortunately, there aren’t many options for folks who haven’t greatly benefitted from those and other treatment approaches. It’s important to have a collaborative treatment team and to be creative and thoughtful about why a patient may be resistant to the treatments they’ve tried. The focus should remain on making sure the patient is safe and that the quality of life they have is optimized through whatever approaches are being trialed.
Is what we know about major depressive disorder over-applied to others who seem to have depressive symptoms but don’t really fall into MDD?
Hughes: For those who may have a depressive temperament, what we used to call dysthymia is now called persistent depressive disorder. For those folks who may not meet full criteria for MDD, it’s helpful to approach treatment in a similar fashion with meds and therapy in combination showing best evidence. We’re really not certain about the cause of depression but understand that it’s the result of several factors (e.g., genetic, biological, environmental, etc.). Focusing on identifying and addressing those contributing factors is helpful, as it would be for any folks presenting with mental health challenges. For many clinicians, the focus is optimizing quality of life and functioning while minimizing safety risks — regardless of the diagnosis a patient carries.
Can you prevent the procrastination that comes with major depressive disorder?
Hughes: There are deficits in the reward (dopamine) system present with depression that may make it difficult for folks to motivate themselves to complete tasks. It’s helpful to try to minimize activities that give immediate gratification. This can optimize reward-pathway functioning and motivation and interest in more mundane or routine activities, like eating, bathing, completing school work, etc. Behavioral activation is a good strategy patients can practice alone or in conjunction with a psychotherapist, and I’d recommend looking into it if motivation is an issue.
What would be your preferred treatment for severe major depressive disorder? Is there any treatment or modality you wouldn’t recommend?
Hughes: Most antidepressant medications work similarly and I don’t have a preferred agent to recommend other than one that’s tolerated best by the patient. Older antidepressant medications (e.g., tricyclics, MAOIs, etc.) are thought of by some to work better (though they have more side effects than contemporary agents such as SRI drugs).
Similarly, psychotherapeutic approaches should be collaboratively chosen between a clinician and patient and should be based on the symptom cluster a patient presents with. It’s hard to suggest a one-size-fits-all strategy. The best evidence is with the combination of medications and psychotherapy. In addition, treatments like ECT or (es)ketamine have a solid evidence base despite prevalent cultural stigmas.
I would suggest avoiding — or at least proceeding with caution — any treatment that doesn’t have supporting evidence based on randomized controlled trials unless you’re open to participating in a research trial for that intervention.
For people who take antidepressants, practice gratitude daily, and still feel unhappy, how do you help those who spend hours on social media, dreaming about living a different life?
Hughes: There may be more to unpack that folks aren’t aware of. This is why it’s important to engage with psychotherapeutic approaches in addition to medications. [It’s great] to practice gratitude daily, as it can be so hard to give oneself grace and feel positive about anything when depressed. Too much social media can be detrimental, and less focus there with more focus on tangible goals and supportive behaviors and activities (e.g. reading, writing, exercise, diet, etc.) would likely have a more positive impact.
What’s your experience regarding medication prescriptions and cost within the American health care system?
Hughes: Oftentimes, due to system-level constraints here in the U.S., mental health visits tend to be rather short. Spending much time with patients can be difficult as a result. Psychotherapeutic approaches take time, sessions may be intense, and longitudinal and frequent follow up is often needed. Meds sometimes may appear to be an easier introduction to treatment and may often be prescribed with more haste than perhaps needed.
Outside of that perspective, many SRIs have relatively benign safety profiles and are relatively inexpensive for most folks (around $5 per month), so they represent a reasonable entry point which should be combined with psychotherapy to optimize outcomes. Many of the newer or branded medications that don’t have a generic counterpart may be unaffordable by most — even with insurance coverage.
One of the big challenges is finding a way to equitably implement novel treatments that perform well in clinical trials. This limits treatments and their benefits to certain groups or populations only, which is problematic.
How can you support someone with major depressive disorder if they’ve stopped talking or engaging entirely?
Hughes: Sometimes, people may present in this way due to reasons such as catatonia or stroke, which would require a medical evaluation (call 911 if you’re worried!). Overall, if you have a loved one or acquaintance who isn’t acting like themselves, providing empathetic support is the first step. Showing them that you’re there for them or that you can offer assistance or support otherwise is key.
If you feel concerned for their mental or physical health (or both), then it’s certainly appropriate to reach out for help — either to others in their support system or outside of it. Check for local mental health resources available in your area as well. Many regions (mostly in urban centers) will have mobile teams that can come assess a person for safety risks or offer helpful suggestions on next steps. Making sure the person is safe is most important, and I’d suggest removing any weapons, sharps, or hazardous chemicals and meds from the environment if you feel concerned. There are also various hotlines one can call, such as 988, which can offer emotional support in real time.
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SOURCES:
Marcus Hughes, MD, psychiatrist, assistant professor, Yale School of Medicine, New Haven, Connecticut.
National Institute of Mental Health: “Major Depression.”
