Talking to Your Doctor About Depression

Dr Larry Culpepper discusses major depression and its symptoms and treatment

/ Author:  / Reviewed by: Robert Carlson, M.D

Depression is more than "feeling blue." It affects about 14.8 million American adults and can have negative short-term and long-term health effects.

In fact, it's the leading cause of disability in the U.S. for individuals aged 15 to 44, according to the National Institute of Mental Health.

One of the first places people can — and should — seek help for depression is with their primary care doctor. Larry Culpepper, MD, MPH, a professor in the Department of Family Medicine at Boston University, shares here what people should know about the symptoms and effects of depression and how to talk to your family doctor and get treatment for the disorder.

Q: Can you provide a layman's definition of major depressive disorder and explain the different types of depression?

Dr. Culpepper: Major depression really involves an extended period (at least several weeks) during which an individual just has no enthusiasm for life and they lose their ability to enjoy things they normally enjoy. They have a sad outlook on life.

Those are the major symptoms, but there are a lot of additional symptoms, such as trouble concentrating, trouble sleeping, difficulty with your appetite and feeling fatigued and run down.

While it's good that we understand depression as a brain disease that involves a lot of changes in the nerve chemistry and the way the brain functions, it also has a really pervasive impact on the individual.

Major depression is best thought of as a chronic episodic condition. It occurs in episodes and these recur throughout an individual’s life. The first episodes often occur during times the person is under a lot of stress, and may last only one to three months.

Later episodes may develop even without stress, and often last much longer. In about 20 percent, major depression takes a very long continuous course.

Q: In what ways does major depressive disorder disable people?

Dr. Culpepper: It certainly affects our mood. It also can affect the body with fatigue, appetite, energy and ability to concentrate. Ultimately, the big effect is that we don't function well in any of the areas of our life, whether it's work, family or social life. In the longer term, it affects our quality of life. We don't enjoy living in the way that we used to.

We also now have evidence that there's a major impact of depression on increasing the risk of chronic illnesses, such as diabetes, hypertension, cardiovascular disease and risk of stroke, and depression increases the risk of having bad outcomes from those conditions.

Paying attention to major depression as part of one's overall health is a very important consideration.

Q: Why is it difficult for patients to talk to their doctors about their symptoms of depression?

Dr. Culpepper: I think in some it's part of the condition. Motivation goes down and sense of futility often emerges, so patients don't bring it to us.

The other thing that is often unfortunate is that these patients often have multiple other conditions and complaints, and those are easier for them to mention to their physician. If they have pain or any number of chronic conditions, we quickly focus on those and don't get at the underlying depression that the person brings with them.

Unfortunately there still is a sense of stigma around depression. While we know it's a brain disease, it's often viewed by our patients as having some sort of poor reflection on their moral character and who they are as individuals, and that's very unfortunate.

Now that we understand it as a disease process, we have very effective treatments both in improving how a patient is feeling and, in the long term, how a patient is functioning.

Q: Can having a chronic illness contribute to depression as well?

Dr. Culpepper: Yes, it's a bidirectional relationship where patients with chronic disease are at higher risk to develop depression and vice-versa. Major depression often develops early in life. They might start experiencing episodes of major depression in their 20s and 30s, and those are often accompanied by changes in body function that make us more likely to develop chronic illness over the years.

The body is under stress chronically and over the years this increased stress contributes to developing the chronic diseases. The way we feel and the impact of depression on our bodies and on our emotions is totally interrelated.

Q: How should a patient go about talking to a doctor if they're feeling depressed?

Dr. Culpepper: Very simply raising the possibility with their physician or nurse practitioner is the first step. From the patient's perspective, what would be very helpful is to say to the doctor, "I'm really having trouble with sleep or concentrating," or "I just don't have any motivation," or "I'm just not enjoying life," the symptoms they are experiencing.

Then it's very reasonable for the patient to go on and say, "Do you think this might be major depression?" First, that tells the doctor this patient is open to discussing whether major depression is a concern. Second, it tells a physician that that is what the patient is worried about.

One of the functions we fulfill in family medicine is to help patients understand their life experiences. I want to help them figure out if that's a real concern or if the symptoms might be due to something else. Raising the possibility of considering major depression along with the symptoms is a major first step.

Q: Tell me about any other physical symptoms of depression beyond the emotional and mental ones besides what you've already discussed.

Dr. Culpepper: One of the things that's often difficult for patients to raise is that major depression may affect sexual function. A part of major depression is that 60 to 80 percent of our patients with it are not engaging in sexual activity that they used to find enjoyable, or there are some real elements of trouble in their relationship.

That is very often part of the disease itself. It's something that, again, we should be aware of, include in our decisions with treatment and include as a goal of therapy the ability to resume having healthy relationships.

Q: Why is it important to seek treatment for depression?

Dr. Culpepper: First off, major depression is a disease, and there can be vast improvement with treatment, so a patient's experience of life can be markedly improved. Second, it's often helpful in terms of a person's critical roles.

With this economy, one of the things that I find is patients coming in that are having difficulty at work. They're depressed, and that's like trying to go to work and carrying around a ball and chain all day.

They often don't function well, and they may be at risk of losing their jobs. Certainly, then, for very practical reasons, it's important to seek treatment.

The same goes for their social and family relationships. Also, if I'm treating them as a primary care physician, I can't effectively treat the other chronic conditions if I don't treat the depression.

Q: Some people may feel the depression is only hurting themselves and not affecting anyone around them. Can you talk about this?

Dr. Culpepper: I think it depends on the individual's own experience with major depression, but frequently a spouse or a parent with major depression is just not fun to be around anymore. They're not ones to spontaneously take the initiative in moving the family to enjoyable things.

It's the parent that sits home instead of going to the ball game with the kids or that doesn't get the family together for fun family activities. It's the parent that the kids don't turn to for help with homework or that the spouse can’t count on for help with household chores that used to be a way of interacting positively.

It can have a very pervasive impact on others in the family.

Q: What are some of the treatments for depression?

Dr. Culpepper: We have a variety of treatments, and we continue to have new treatments that are strong advances in the field. The two main approaches to treatment are medication and psychotherapy, and they both work well.

With more severe illness, we recommend medication because it works more rapidly, but we use both approaches. Within the medication realm, we have a number of different groups of medications. For example, vilazodone is the name of a drug that is the newest with FDA approval, and it has a significant potency in helping a patient with major depression. Its side effect profile is also good.

Medication is what I find most patients prefer — they don't have the time or the financial resources for therapy, or they may not have the interest or motivation to go that route initially. Often, once their symptoms improve with medication, they may find additional benefit from engaging in therapy as well.

Note: Dr. Culpepper is a paid consultant for Forest Laboratories, which manufactures vilazodone as the brand name medication Viibryd.

Q: What are some "natural" ways to combat depression?

Dr. Culpepper: Certainly the therapies that we know have strong effectiveness need to be the mainstay of treatment, but we also know that the patient who maintains regular exercise gets a boost in the major form of treatment. Definitely getting into a regular exercise program can be very important and helpful for these patients.

There have been some herbal approaches that have been recommended and studied, though the problem with those is that we don't know the dose they are taking and some have real potential for drug interaction, where they can have adverse impact on other drugs the patient is taking.

Exercise is the most important, and certainly yoga and other forms of relaxation can be helpful. Getting regular sleep, avoiding too much caffeine and everything in moderation all can be helpful. It's not that a person shouldn't drink at all when depressed, but they certainly shouldn't binge drink or drink to excess.

Q: When a patient is depressed, they may feel that it's impossible they will ever feel good again. Can you talk about the outcomes of people who seek treatment?

Dr. Culpepper: What we find is that initial episodes of depression in a person's life are often brought on by other stresses, but after two or three episodes, we find the depression takes on a life of its own. The other thing we find is that the episodes become more frequent and more severe and last longer as people have additional ones. What we want to do is recognize depression as a condition affecting an individual early so we can influence that long-term course.

The impact is pervasive. What we find in a number of large multiple-analyses of studies is that a patient with major depression is three and a half times less likely to stay with their other treatments (for depression and for other illnesses).

They don't stay on their diet or stay on their cardiac medications or diabetes medications. They don't adhere to recommendations for their lifestyle, so it puts them at greater risk for other problems.

The key with this is selecting an initial therapy that is not going to itself cause a number of problems. Sexual function is a component of depression, and another common issue is weight gain.

Often depression and obesity occur in the same individual, so if we select a treatment that itself may cause weight gain or sexual dysfunction, it may interfere with the patient staying on those treatments long-term.

Vilazodone as a new treatment may be particularly useful because what we see in year-long studies is that it doesn't affect weight gain beyond what the usual American experiences and it appears to have very little difference than placebo on sexual function. The long-term impact of treatment and selecting the right agents can be very very valuable.

Q: What do you do if you suspect someone you love is potentially depressed?

Dr. Culpepper: That's the way we often see patients brought in — a loved one has encouraged them to come in. While most sufferers of depression are women, a third of all cases of depression are men. Men in particular may be reticent from thinking about it as an underlying cause. If a man is depressed, he may think, "Well that's just not what happens to men."

It's a matter of recognizing the symptoms not just over the last day or two but over the past weeks or months. A person could say to another, "The stress you've been under at work is really having a toll on you. Maybe you have major depression at this point."

Many times someone is very open to having this suggestion. If it's a concern, you could say to your spouse, "Hey, why don't you see a doctor about how down you're feeling or about how much trouble you're having sleeping, or about the weight gain or the weight loss."

Pushing the individual to see a doctor for the most problematic symptoms may be the best course for a family because that's often what the patient is complaining of.

Then you can tell them, "Seeing a doctor is something you're really doing for yourself and our family and I appreciate it." It's something the individual can take control of, so you can frame it in a way that's supportive of the individual going and seeking treatment.

Q: Is there a way to prevent or reduce the risks of depression?

Dr. Culpepper: Unfortunately we don't have good evidence that depression is truly preventable. We know that often times insomnia is part of the profile for major depression. If the person is not sleeping well, that person may be at high risk for an initial or repeat episode of depression.

Having a regular exercise program can be very helpful, and if they have past episodes of depression, I encourage exercise to reduce the risk of future episodes.

Monitoring stress in one's life, recognizing it and reflecting on it, particularly if we're not coping with it well or sitting back and thinking about what are our coping strategies and how they might be improved, may be helpful in preventing that from developing into a chronic stress situation or depression. Regular relaxation, and building into busy schedules activities that a person enjoys, and that help build their social and family connections can be helpful.

Often it's a matter of secondary prevention. If a patient has had one episode of depression in their life, the first one’s often stress-related and 50 to 60 percent of the time they will go on to develop another episode within 5 years. If we stretch it out to 15 years, 85 percent of the people will have another episode.

The question is how do we prevent those additional episodes? After two or three episodes, most patients get treatment.

Another part is early recognition and being aware and knowing if it's in your family. If an individual does have depression and has had several bouts and is on long-term maintenance therapy, selecting a treatment that is both effective and unlikely to cause chronic side effects is important. It's both primary prevention and secondary prevention that need to be considered.

Q: Any final thoughts to emphasize?

Dr. Culpepper: Again, I would just stress that integrating depression treatment with treatment of other chronic conditions is particularly important to getting the best outcomes with all the conditions that may be affecting a patient.

Review Date: 
September 30, 2012