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Bill Klaproth (Host): So, how do you know if someone is depressed? What should you look for when it comes to depression? Can someone cover up depression? There’s a lot of questions when it comes to diagnosing depression and the goal of this podcast is to provide answers and help you discern whether someone is depressed or not. Here to help us get those answers is Dr. Adam Rosenblatt, Director of Geriatric Psychiatry and UM Upper Chesapeake Health.

This is the Hero podcast from UM Upper Chesapeake Health. I’m Bill Klaproth. Dr. Rosenblatt thank you so much for your time. So, I know there are screening tools that are used for depression but what about other ways of detecting it?

Adam Rosenblatt MD (Guest): Well the screening tools are typically used in a situation where you don’t know the person very well and there might be a very brief interaction and so the idea is to be very inclusive and identify those people who you need to ask more questions about. The gold standard for telling if somebody is depressed is still a full interview with somebody who ideally you have know for a while. So, you know what they are like when they are usual and when they are not their usual selves.

So, you would look for changes in somebody’s behavior. You might look particularly for what we call vegetative changes, people that have lost their appetite, people that are unable to sleep at night, those kinds of things. And so, this might apply not only to a patient that you are interacting with but maybe your colleague or a family member, somebody who seems to have lost their interest in things. Somebody who seems sad and withdrawn. And really the best way to tell if somebody is depressed is to ask them whether they feel depressed or whether they think that they are depressed.

And the same thing goes for asking people about suicide. There are myths that people won’t talk to you about these kinds of things. But oftentimes the depressed person feels very alone and helpless and so if they have a concerned person say boy you don’t seem like you were the last time you came to see me. You seem withdrawn. You seem sad. I noticed that you were tearful when I was asking you about your health. Do you think you might have depression, is a very good way to step right into it and if you give the impression that you are comfortable talking about it and that you are going to not be judgmental, that you are going to be supportive and do something to help; people will often open up to you.

It is important to have enough time to have that conversation, so sometimes you might be planning to see somebody for ten minutes and you end up having to delay everything. And so, you want to be supportive and then maybe you may have to say, this is very important, I want to talk to you more about this. can I come back in an hour or can you come see me tomorrow or you may need to draw out the visit.

Host: Right. So, it sounds like what you’re saying if you approach it the right way, people will open up to you. Because I’m wondering if people would say there is still a stigma about mental health, nope, I’m not depressed, I’m fine. I’m fine. But it sounds like you have to approach it the right way to have somebody open up and say you know what yeah, I have been feeling down. I have been not interested in things. I have noticed a change in my behaviors. Is that right?

Dr. Rosenblatt: I think that’s right. People need to know that you are not judging them. They need to feel like you have enough time to have a discussion with them. So, I think scales and instruments are very important and they detect a lot of cases of depression that need to be looking into further. But it can also be pretty cold and so, sometimes people may not feel like opening up on the basis of nothing but a scale. But I also emphasize to people that it’s the patient who filled out the scale. So, that’s what they are telling me about themselves. So, if somebody fills out a scale that they can’t sleep and that they think about death and that nothing is any fun for them, the future looks hopeless; and then I say to them I want to talk to you about depression, I’m concerned some of the things that you filled out here suggest you might be depressed and then they’ll say what, that’s outrageous. And I say well this is what you told me about yourself, you are the one who filled out this scale. So, look at all the things that you identified as being problems.

So, I think sometimes the idea that depression is a syndrome and that not everybody is upset about some particular thing is a tough ting for a lay person to wrap their brain around. And so you have to say to the person, look you identified all of these different symptoms of depression and so, you might have this. we should talk about it. the same way as if you were telling somebody that they had diabetes.

Host: Right. So, can someone be depressed and not realize it?

Dr. Rosenblatt: Well they can. I mean I wouldn’t say that it’s common, but it certainly does happen. Or let me put it in a different way. Somebody may feel bad, but they may have an explanation for why they think they’re low mood came about. And it could be true, but sometimes it really stretches your imagination. So, I had a lady one time who was partway through a course of treatment for severe depression and then she told me I don’t need any more treatment, I figured out why I’m depressed. My mother never really wanted me. And I said well that’s very interesting and so you could talk about that with a therapist, but you are 62 years old and your mother’s been gone for decades. You just figured this out now? I don’t know that that explains what’s happening today.

So, one of the things we have to ask ourselves is why is this happening now. And the fact that somebody may have had some disappointments in life or may have some chronic issues doesn’t necessarily explain why they’ve become very depressed right now. So, I don’t think that every single depression is a disease. I think there’s probably different kinds and different causes of depression and we can guess at what we think is causing this one or that one and we can talk more about that in a minute. But sometimes people will have the syndrome of depression, but they’ve convinced themselves that there’s a logical explanation.

And then you have some people that are just really not in touch with their feelings at all and so I think – I tend to see that in people for example, that had a very rough childhood or upbringing. So, if you were very badly neglected as a child or abused; then the lesson I think you learned was that it doesn’t do any good to cry, nobody will help you with your problems. You should just stuff everything down and act like everything is fine.

Host: So, you suppress your feelings, then.

Dr. Rosenblatt: Exactly. And so some people like that will deny even feeling depressed. They act depressed. Everyone around them thinks they look depressed, but they deny that that’s happening to them and they just – they have difficulty accessing their own feelings. So, I think there’s also people like that. So, yeah it is possible for a person not to realize that they are depressed. I think most people do, but sometimes you have to convince somebody that they really have this problem that they need help with.

Host: And then there may be some people that may try to cover it up because they want to seem strong and I’m fine, don’t worry about me, I’ve got it all together, I’ve always got it together when inside, they are under duress inside. Is that possible too? I mean people do try to cover this up?

Dr. Rosenblatt: A lot of people’s self esteem is wrapped up in always appearing strong and never needing to ask help for anybody, if that’s your kind of persona or that’s the role that you fill in your family or in your workplace or in your community. It may be very hard to admit that you need help and so people will try to cover it up. And then also the scariest cases are people whose depression is so severe that they’ve lost touch with reality and so sometimes they may try to cover up their depression because they have an irrational fear of something happening if anyone finds out. So, I think, it might have been Brooke Shields said that she had postpartum depression and she was afraid that if anyone found out that she was depressed that her child would be taken away. Now this certainly wasn’t realistic but that’s the kind of irrational fear that can run away with you if you are in the midst of a depression.

I once had a patient who tried to kill himself and as he was recovering everybody wanted to know what was the last straw, what had driven him to this desperate act. And he told me that he had been embezzling money and he was about to be arrested. And it turned out a few weeks later, after his wife and his friends looked into it, that that wasn’t true at all. It never happened. It was all a delusion. So, sometimes in the most dangerous cases, a person may cover up their problem because they have some irrational fears about what will happen if someone finds out. But usually it’s people who don’t want to appear weak.

Host: All right. So, it sounds like there’s different levels of depression. Is that right? Or are there even different kinds of depression? Tell us about that Dr. Rosenblatt.

Dr. Rosenblatt: Well I think there are different ways of looking at different kinds of depression. There are different flavors of depression. So, for example, there are people whose depression is very agitated and anxious. There are people whose depression is characterized by inability to sleep and lose of appetite. There’s people with those symptoms seem to be reversed. So, sometimes depressions are classified on the basis of their symptoms. Sometimes people classify them on the basis of their severity, mild, medium and severe just based on how disabled you are by it.

There are depressions where people have psychosis, delusions and hallucinations and depressions where people don’t. And then people classify them on the basis of what they think is causing them. But this is really anybody’s guess. So, I think there are probably some people whose depression is very biological, and it runs very strongly in their family, there is no apparent cause for it. It comes up out of nowhere, it’s very severe. So other people at the other end of the spectrum where it seems like their depression has an explanation. Maybe they are grieving or a lot of very negative things have happened to them all at once. And then there’s this huge gray area in between where it’s very hard to know for sure if the person’s depression is about something or if they have a disease.

So, a lot of people come back from the doctor and the doctor says you have a chemical imbalance. That’s our hypothesis but we don’t really know. So, we have to look at each depression individually and try to figure out what’s the right combination of treatments that might help this person to recover.

Host: Right. That makes sense looking at each person individually. I would imagine as you were saying, it would be toughest to diagnose someone with a mild case of depression and you said is it about something or is it a disease. So, what is the difference then between having depression and being upset about some stressful things that have happened in your life?

Dr. Rosenblatt: Well generally speaking, we would say that if a person doesn’t have the full syndrome, so maybe the person is very upset about something that’s happened in their life but nothing like this has ever happened to them before, they don’t have all of the symptoms of depression. For example, they may still feel good about themselves and just say I have just had a lot of bad luck or they may still be able to enjoy things if something bright were to come along in their day, they are not miserable 24/7. So, a person who is upset about something might not have the full syndrome. But sometimes they do.

It is not always possible to tell. And so, if somebody’s depression is not very severe, then we might say well let’s start out with some counseling and give you a chance to talk about the problem and do some problem solving and express yourself and see if you begin to feel better by doing that. Generally, we would offer medication to somebody whose depression seems more severe or more life threatening.

What we know from the available scientific evidence is that people seem to do best with a combination of medication and therapy, medication and counseling than either one all by itself. But there are some forms of counseling that seem to be as effective as medications in people with mild to moderate depression. So, not everybody has to take a medicine for depression and whether or not they should is based on what has worked for them before, what their preference is, how severe of a depression it seems to be and those kinds of things. There’s always a dialog between the doctor and the patient about whether medication is something we should try sooner rather than later and what drug to choose and how to dose it and those kinds of things.

There’s a negotiating process. And then if somebody’s depression is very severe, they may need to be admitted to the hospital and so that would be typically for somebody who is actively suicidal or somebody who is so depressed that they can’t take care of themselves, they are not eating, they are not drinking, they are not getting gout of bed, that sort of thing. And that’s for the most severe cases.

Host: And then when it comes to treatments, basically it’s on an individual level. You mentioned some forms of treatment. Counseling, problem solving, medication, even admitting somebody to the hospital. So, you look at that person as an individual and what they are going through and their symptoms to understand what is the best method of treatment?

Dr. Rosenblatt: Absolutely. And sometimes we can’t always tell in the very beginning. So, what I say to somebody is I say, I don’t give up very easy. I’m going to work with you until you either get better or you get tired of me. But I’m not going to get tired of you. And so, we’re going to try different things and it might be that the first thing we try isn’t a success. That’s not the end of the world. That happens in every branch of medicine. You might have high blood pressure. The first blood pressure medicine you try has causes or side effects; it doesn’t work for you. Or maybe you just needed to eat less salt.

So, we’re going to work through this together and we are going to discover what’s the best treatment for you and then once we know what works for you, then if this happens again, I think it wont take us this long to figure it out.

Host: So, working through it together, a collaboration between the patient and the physician. So, with depression, always comes the big question. How can you tell if someone is suicidal?

Dr. Rosenblatt: Well that’s a very important question. It’s hard to be positive because people will sometimes cover it up and obviously, there are many sad instances where someone kills themselves and people didn’t suspect that they were in such a bad way. But I can tell you this. You wont find out if somebody is suicidal if you don’t ask them about it. So, it’s very important if you know that a patient of yours is depressed or a friend or a colleague or family member; to say to them, heh listen, I really care about you and I want to know have you been feeling so depressed that you’ve been thinking about suicide or you’ve been thinking maybe in a more passive way that life isn’t worth living or that you just wish you wouldn’t wake up in the morning.

And there are a couple of myths about it. Some people think that asking a depressed person about suicide will give them the idea. That’s really not true at all. They’ve already thought about it. And then the other myth is that nobody will ever tell you the truth if you ask them about suicide. So, some people say why should I ask someone about suicide, if somebody is going to kill themselves, they will just do it. But long before somebody takes that step, people are ambivalent. We have survival instincts. So, even somebody who is very depressed and thinks about suicide a lot there is part of them that wants to get better and wants to live and that’s the part I’m trying to reach. And I will put it in exactly those words to somebody.

So, many people that are having suicidal thoughts will tell you the truth about it if you show that you care, and you ask them about it more or less directly. And then if they are feeling suicidal, then we have to try to decide how dangerous it is and what steps can we do to make the situation safer.

Host: Right. So, you won’t find out if you don’t ask. So, I think that’s really important. So, then you were just getting into ways to prevent it. So, what can we do to prevent suicide?

Dr. Rosenblatt: The most important way to prevent suicide is to identify people with depression and treat them. And ideally treating people before it even gets so bad that it comes to that point. And so they never become suicidal in the first place. If somebody already is suicidal, in the more severe cases, you may have to admit them to the hospital. Sometimes even regrettably, they may have to be admitted to the hospital involuntarily. I hate doing that and it’s not my favorite way to work with patients. But I’ve had people who were admitted involuntarily because either they have already made a suicide attempt or they were planning one and when they got better, they almost always said, thank you very much for taking care of me even when I couldn’t care for myself. I understand you did what you had to do.

Some people are still mad about it. But I think if it’s a matter of life and death, occasionally, that’s what you have to do. Many people will enter the hospital voluntarily and they may need to be observed 24 hours a day for a period of time if they really strongly are thinking about hurting themselves. Shy of that, you can do things like make sure that the person has a number to call when things seem out of control. You can remove hazards like ask them if they have guns in their house. Ask them to give them over to some friend or family member for safekeeping where they take them out of the house. I know people that have died because the family didn’t think they knew where the gun was, and they did know where the gun was. So, it’s really not safe to have firearms in a house with someone who is suicidal.

I’m not saying they have to be gone forever, but you should remove them. If the person has a lot of medicine lying around from old prescriptions that could be dangerous; you should clean that up so that there’s not things there because many suicides are impulsive. So, the person thinks about it but they haven’t really resolved to try and then maybe the middle of the night they are feeling particularly desperate and there is no one to talk to and they might impulsively attempt suicide. And if they don’t have an easy way to do it, that might help the person make it through to the next day and be able to tell somebody and get some help.

Host: So, for a healthcare provider, trying to discern whether or not someone is depressed; what is the first thing they should do?

Dr. Rosenblatt: Oh that’s a good one. I think I would ask the person how do you feel. And then when they say I feel lousy, I’m sad, I’m miserable; I say do you think you might have depression? And I let them tell me what they think. Most people have some idea of what’s meant by that. And so, the first person’s opinion I want to hear is the person who is suffering it because they would know it best.

And then it can also very helpful to speak to their friends and family if they will allow it. And say well do you think he has depression. Sometimes I’ll ask people to think of the saddest they have ever been about some real world thing like their parent died or something and then I’ll say well does it feel like this or does it feel different somehow. And people with clinical depression, they often say it feels different than grief. That it almost worse somehow. So, I might ask them to compare to things that have happened in their life.

Host: So, speaking of getting help, can you tell us about the Klein Family Harford Crisis Center?

Dr. Rosenblatt: Oh yes. This is something that we are all very proud of because out institution has really been putting a lot of time and energy into behavioral health. So, if a person is in trouble, they might speak to their primary physician. If it’s a matter of life and death, you might go to an emergency room or call 9-1-1 but what if it’s very urgent but it doesn’t quite fall into those categories? So, the crisis center offers behavioral health and addiction services and has a 24/7 hotline. And the telephone number is 1-800-NEXT-STEP, N-E-X-T S-T-E-P. That’s 1-800-639-8783. There’s also outpatient services from 7 a.m. to 7 p.m. and you can walk-in urgently for those services as well. And in the future, we are going to have crisis beds and have expanded hours. But right now we have walk-in from seven to seven and we have 24 hour hotline. And those people can help you to get a timely referral so that you can be seen on an urgent basis somewhere and start to get help right away if things are really coming apart.

And so, we are very proud of this venture and we hope that that’s something that people in our community will avail themselves of.

Host: Well that is the hope and thanks for talking with us today Dr. Rosenblatt. That number again 1-800-NEXT STEP. 1-800- NEXT STEP a really important number. This is the Hero podcast from UM Upper Chesapeake Health. A podcast for internal communications. Check back for our next episode soon. I’m Bill Klaproth. Thanks for listening.