Amanda Wilde (Host): Feeling sad sometimes is a natural part of life, but depression is a medical condition and it can range from mild to severe. Today we'll focus on addressing severe depression with Dr. Juliet Glover, Geriatric Psychiatrist with PRISMA Health.

 This is Flourish, a podcast brought to you by PRISMA Health. I'm Amanda Wilde.

Welcome, Dr. Glover.

Juliet Glover, MD: Welcome, Amanda. Thank you for having me.

Host: It's great to have you here. Let's talk about depression in general terms, first of all. What is depression? How do you define it? And when is depression considered severe?

Juliet Glover, MD: I think that is a great place to start. Depression is a chronic medical condition, much like other chronic medical conditions like hypertension or diabetes. And it is also a condition that can be recurrent, which means an individual can have multiple episodes of depression throughout their lifespan.

Depression is marked by symptoms that affect both the mind or the emotions, but also symptoms that affect the body. So some of the symptoms of depression include a low or depressed mood and a loss of interest in activities that the individual used to enjoy. Along with that, a patient suffering from depression may experience excessive feelings of guilt or feelings of worthlessness, and sometimes feelings of hopelessness about their situation.

This can sometimes progress to thoughts about life not being worthwhile or thoughts about suicide. And we will often advise anyone who is having these types of thoughts to reach out to their healthcare providers, their mental health providers or even the national suicide prevention lifeline at 988.

In addition to these emotional symptoms, depression can affect the body. So an individual may experience changes in appetite. Either eating too little or eating too much with associated weight gain or weight loss. They might also experience difficulties with sleep, sleeping too much or sleeping too little. Trouble falling asleep. Trouble staying asleep. They might notice problems with energy where they feel tired all the time. They might notice that their movements are slowed. Their body feels heavy. Or even the opposite, having too much movement, agitated, pacing. And then lastly, difficulties with concentration or even subjective or objective difficulties with their memory.

And so these are the symptoms that would characterize depression and based on the number of symptoms or the severity of the symptoms and how these symptoms are affecting the individual's ability to function in their day to day, that would tell us whether the depression that the individual is experiencing is mild, moderate or severe.

Host: When we talk about depression in general, if we can for a moment, how is it typically treated? And then we'll talk about treating severe depression.

Juliet Glover, MD: So depression, first line would be psychotherapy, if an individual is experiencing mild depressive symptoms. If the symptoms are more moderate or severe, then typically we look at antidepressant medications. The first line would be medications of the class, called SSRIs or selective serotonin reuptake inhibitors.

And these are medications such as fluoxetine or sertraline. Quite common medications that an individual has to take every day for a minimum of about six to eight weeks before they would start to notice the benefit. And oftentimes we recommend individuals maintain the medications for about six months or longer if they had a severe illness or if they've had recurrent illness to prevent subsequent episodes of depression.

So as you can see, it's a multi modal treatment, plan with psychotherapy and oftentimes psychotherapy plus medications.

Host: And then, if you have severe depression, do you find these treatments don't work as well? And what are your treatment options if you have severe depression?

Juliet Glover, MD: So with severe depression, sometimes in addition to the symptoms I mentioned, individuals may develop psychotic symptoms. They may start to hear voices or have delusions, fixed beliefs that people are out to get them or that they're a terrible person or they've done something wrong.

And so in addition to the antidepressant medications, they may need an antipsychotic medication. Sometimes when depression is really severe, individuals may develop catatonic symptoms where they essentially become stuporous. They may not talk, become mute. They may not move. If they do talk, it's in a very kind of stereotypical fashion or disorganized fashion where they might echo what another individual says or echo the actions of another individual.

And so they're not really able to interact with the external world in the way that someone who isn't experiencing that severe depression might. And so in this case, they may require an additional medication called a benzodiazepine. Now, if someone has such severe depression with some of these associated symptoms, we would use the appropriate medications to target these specific symptoms, but sometimes medications just don't work, especially if depression and these other associated symptoms have been present for a long time, or sometimes individuals go through multiple medications.

They go through, you know, one medication, then a second and then a third. And so the depression may be considered treatment resistant, which is when an individual has failed at least two antidepressant medications at an adequate dose for an adequate period of time. And so when we have this kind of situation, we start thinking of other methods of addressing the severe depression such as, electroconvulsive therapy.

Host: Can you talk about that a little bit? How is electroconvulsive therapy performed?

Juliet Glover, MD: Electroconvulsive therapy, if I can just start by giving brief background, it's a treatment that's been around for a really long time, since about the 1930s, when the observation was made that individuals who had seizure disorders as well as psychiatric illnesses, whenever they had a series of seizures, their psychiatric symptoms seem to get better.

And so the thought was can we mimic a seizure or induce a seizure, if you will, but in a very controlled setting? And that is exactly what electroconvulsive therapy or ECT does. It's a procedure that's performed in either a procedure or an operating room style setting. It's performed under general anesthesia.

So the individual is given medications and they're asleep throughout the entire procedure, which is a relatively brief procedure, usually takes about 15 minutes from the time in the room to the time out of the room. In addition to the general anesthesia, the individual gets a muscle relaxer, so they don't have any kind of vigorous motor movements that you might expect from an individual who is having a seizure, and the goal is to induce a brief seizure, so that we can see the subsequent clinical benefit from that.

And it's also a monitored seizure. So the anesthesiologist and nursing staff are monitoring vital signs, EKG, oxygenation levels. And as a psychiatrist, we're monitoring an electroencephalogram, or an EEG to make sure that the individual has the seizure and then that the seizure stops. And and that's essentially what the procedure consists of.

Host: And what happens to the brain during electroconvulsive therapy?

Juliet Glover, MD: So again, the goal is to induce a generalized seizure. And so during the seizure, there's increased brain activity. I will say the exact mechanism of action of ECT is not really known. What we do know is that there is a generalized release of neurotransmitters in the brain. So the same neurotransmitters that the antidepressants target, the serotonin for example, norepinephrine, dopamine, we have a generalized release of these neurotransmitters when the brain is active during the seizure activity. There's also increased blood flow to the brain. There's evidence that there's increased neuronal connections. And all of these changes that are happening, some of which we don't really have clear definitions of what's going on; but these changes lead to very clear signs of clinical improvement. If you were, for example, to look at the remission rates for an individual who is suffering from depression who has had ECT, the remission rates are upwards of 80%, which is much higher than any response rate you would get from medications alone.

Host: So does that mean you have a higher success rate with severely depressed patients than with perhaps moderately depressed patients?

Juliet Glover, MD: Well, actually that is true. Individuals who tend to respond more robustly to ECT are those suffering from severe depression who may also have the associated psychotic symptoms I mentioned like hearing voices or delusions or even the catatonic symptoms I mentioned. Those individuals tend to respond more robustly to ECT.

But that being said, even individuals who may have more moderate forms of depression can still benefit from ECT treatments.

Host: You said this kind of therapy, ECT, has been around for a long time, but obviously it's been refined a lot to where it is now. Is it safe? Are there side effects? Can you talk a little about that?

Juliet Glover, MD: Modern day ECT is very safe and as you alluded to, there have been a lot of advances in the technology, but also in the technique and there's ongoing research on how to further improve how we do ECT. So some of the things that have changed over time as well, you know, when they first started, they weren't using anesthesia.

Now it's done under anesthesia and has been for decades. It's also monitored. I mentioned some of the monitoring that takes place, with vital signs and the EEG monitoring. The other thing, you asked about was side effects. So as with any treatment, medications, whether it's antidepressant and antipsychotic medications, they're going to have the potential for side effects. With ECT, the more common side effects include a mild headache after the treatment. Sometimes individuals don't take anything for it and it resolves on its own. Sometimes it just requires over the counter analgesics like acetaminophen or ibuprofen, for example. There's also, you know, after a seizure, an individual may feel a little groggy, feel a little confused, and that tends to resolve over minutes to hours.

In terms of the biggest side effect we worry about with ECT and that we take active measures to try to reduce and to monitor are its potential impact on memory. So during the course of ECT, an individual may notice that they have difficulty retaining new information or they may not retain new information as well as they did before the series of ECT.

But after the series is complete, that usually will resolve or even be improved because now they're no longer depressed and they're more motivated, their concentration's better, they're sleeping better. And so sometimes people will notice that their memory actually gets better, but ECT has been associated with some memory difficulties, both in retaining new information, as well as in forgetting bits and pieces of past information, around the time of their treatment. More remote memories, old memories from years prior are typically not affected by ECT. And as we started off talking about, with the advances, the way we do ECT now, has been associated with a lot less of these cognitive changes.

Host: Interesting. You mentioned that people might have better memory when they're no longer depressed. Can ECT cure depression?

Juliet Glover, MD: That is a point I always make with my patients that ECT is a treatment and not a cure. So much like the medications, they treat the symptoms, ECT can treat the symptoms. It can induce remission, but it doesn't prevent someone from having a subsequent episode of depression.

And so everybody who gets ECT treatment, we typically will recommend that they continue some form of additional treatment, be it psychotherapy, be it medications, be it additional ECT, but on a less frequent basis. So a typical ECT series, for example, is about anywhere from 6 to 12 treatments.

So it's not just a one time procedure. It's typically done three times a week, and an average individual would need anywhere from six to twelve. But after that is complete, and let's say the individual has reached remission of symptoms, they would still need to continue to see their therapist, to take their antidepressant medications, and for some individuals, they continue on with ECT, but at a much less frequent rate.

Host: With the advances in ECT, are there any other conditions ECT is used for?

Juliet Glover, MD: So let's start with what it is approved for. It is approved to treat severe major depressive episode. And you can have major depressive episode as part of just major depressive disorders. So an individual who only has depressive episodes, or an individual who has bipolar disorder and has manic episodes, but also the depressive episodes.

So ECT can treat the depression associated with both disorders. It's also approved for catatonia. So I talked about how individuals may have severe depression and become mute or stop interacting with the world, for example. Catatonia can be associated with, multiple other disorders, schizophrenia, for example, or with mania.

And so if that is the case, if they're having catatonia irrespective of whether it's linked to the depression, ECT is approved for that. Apart from a major depressive episode in catatonia, we also can use ECT to treat mania, to treat acute psychosis in someone who has schizophrenia or schizoaffective disorder, for example.

And there's also growing literature of ECT being used to treat agitation in individuals who have dementia, and even case reports of improvement for refractory obsessive compulsive disorder. And so there's a lot of things that ECT may help with, and there's evidence that it helps with, but its use would be off-label for some of these other conditions.

Host: But that happens with a lot of medications, right?

Juliet Glover, MD: It does, absolutely.

Host: Well, Dr. Glover, thank you so much for explaining both severe depression and ECT as a proven effective method for addressing severe depression. Really appreciate you bringing ECT to our minds in the modern era.

Juliet Glover, MD: It's always a pleasure to have something to offer patients when, you know, sometimes we get into a corner and don't have much options. And so for me, the take home is that, depression is a treatable condition and there are many different ways to treat it. And if anyone is out there suffering and maybe the current method of addressing symptoms, aren't working, to consider other treatment modalities. And it's been such a great pleasure to talk with you about this topic.

Host: That was Dr. Juliet Glover, Geriatric Psychiatrist at PRISMA Health. For more information and other health podcasts, visit prismahealth.org/flourish. This is Flourish, a podcast brought to you by PRISMA Health.