Prakash Chandran (Host): Have you ever felt like a dark cloud is hanging over you, making it hard to enjoy the things you once loved? Or maybe someone close to you seems stuck in a cycle of sadness and fatigue. These could be signs of major depressive disorder, a serious but treatable condition that goes beyond just feeling down or having a bad day. Here with us to discuss about managing major depressive disorder is Dr. Muhammad Awais Aftab, a psychiatrist with Southwest General Medical Group.

This is Southwest General Health Talk. I'm your host, Prakash Chandran. So, Dr. Aftab, thank you so much for joining us today. I really appreciate your time. Now, a lot of us have heard of general depression, but I'd love for you to tell us what major depressive disorder is.

Muhammad Awais (“Awais”) Aftab, MD: Thank you for having me and thank you for initiating this discussion. Major depressive disorder is one of the most common mood disorders across the world. And it is a weird form of depression, also known as clinical depression. And it usually happens when people are stuck in an intense state of low mood, loss of interest in life, and this is accompanied by several other symptoms such as sleeping difficulties, changes in appetite or weight, changes in energy, a lot of guilt, low motivation, difficulty concentrating, and in some cases, even suicidal thoughts.

And if these changes are persistent and ongoing, and if a person is experiencing down, low mood, loss of interest, most of the time, most of the days, for at least a two-week period, then it enters the territory that we call major depressive disorder. There are other kinds of depressive disorders as well. But major depressive disorder is the most common diagnostic category and the main form of clinical depression that we recognize.

Host: Okay, thanks for the explanation. I'm curious as to is there a trigger that causes the onset of major depressive disorder or something that happens that helps it or causes it to evolve faster than a normal depressive disorder?

Muhammad Awais (“Awais”) Aftab, MD: There a lot of different causes, and the exact combination of causes and triggers varies from person to person. Some people have a more physical or biological flavor of depression, where they experience a sudden onset of low mood and low physical activity, low energy. And there isn't any obvious thing in their environment or in their social circumstances that seems to have initiated it, versus there are other people for whom a depressive episode is linked to some kind of stressful life events. They might be experiencing extreme stress at job. They might be experiencing relationship difficulties or marital difficulties. They might be experiencing financial difficulties. And those life stressors get to a point where they start feeling overwhelmed, and they enter a depressive episode.

So, we see all these different kinds of combination, and it's also the case that many people who have had histories of trauma or abuse during their childhood, they are often predisposed to developing depression later in their life. And then, some people are genetically predisposed to experiencing depression during moments of stress. And there are certain personality characteristics, such as people who are high on neurotic traits that have a tendency to experience depression as well with circumstances that might be okay for other people. For those people, they would see themselves as being overwhelmed and experience an episode of depression.

Host: I wanted to ask you about how it actually represents. With someone with major depressive disorder, are they able to be high functioning in life normally and then go home and experience these feelings, or is it pretty debilitating and they're not able to do anything?

Muhammad Awais (“Awais”) Aftab, MD: In the classic textbook form of this disorder, it's usually pretty impairing. And their personal life is affected, their work life is affected. They're not able to perform at the same level of functioning as they are at their normal level of self. And in severe cases, they might even have to take a medical leave from their work or from their studies.

But there are milder forms of clinical depression in which a person can continue their everyday functioning. So, they're feeling depressed, they're feeling distressed. But they're able to, with effort, compensate for that and continue working. And these are cases where depression can go undiagnosed for long periods of time. Because from outward appearances, it seems as if the person is doing okay, it seems as if they're doing their job, or they're maintaining their regular studies, but subjectively, they're feeling very down, they're feeling very depressed and stressed. So, that can happen too.

Host: Now, I want to talk about when to seek help. But before I do, is there a general time in one's life where the onset of major depressive disorder might come about?

Muhammad Awais (“Awais”) Aftab, MD: The classic textbook description of that is that people in middle age are more susceptible to it. So, adults in their 30s, 40s typically tend to experience more episodes of depression. And this also could correlate with the fact that people in that age group are experiencing work stressors and family stressors and life stressors, et cetera. And then, there's another group of people who experience depression in their old age. And this is often related to changes in the brain that happen with aging as well. It was historically believed that younger people and young adults and teenagers were at a lower risk of experiencing depression. And that had been the case for a long time. But in the last 10 years or so, we have seen very high rates of depression and anxiety emerge in the younger generation as well. So, this traditional idea or the conventional wisdom that major depression is primarily a problem of middle-aged and older adults has been disproven, you can say, because so many more young adults are now experiencing depression and anxiety as well. So, at this point, it's safe to say that anyone at any age can experience this.

Host: Okay. You know, you alluded to the fact earlier that if you were experiencing some of these symptoms for a two-week period, it may be time to seek help. Is that the right assessment? If someone is really unable to get out of this hole that they feel like they're in, is that the right time to reach out?

Muhammad Awais (“Awais”) Aftab, MD: The right time to reach out depends on the negative impact on a person's life and how severe that the symptoms are. If the symptoms are very severe, for example, if someone is feeling extremely depressed to a point where they are experiencing suicidal thoughts, then even if this has been going on for just a few days, I would encourage them to get help, because it means that they're experiencing some form of mental health or some form of psychiatric distress that requires clinical assessment and clinical treatment.

The two-week time frame is essentially a guideline for clinicians to consider. And this is used to help demarcate forms of depression that might be transient or self-limited, where someone experiences an upsetting episode and some kind of stressful life event, and they are depressed for a few days, and then it resolves on its own. So, the two-week time frame is a somewhat arbitrary threshold set to separate the self-limiting conditions from conditions that are persisting on, and conditions that are going on for a longer period of time. But it's a loose guideline. And if someone's functioning is affected to a great degree, or they're experiencing concerning symptoms such as suicidal thoughts or severe changes in their physical functioning and their energy levels, then they should get help regardless of how long it's been going on.

Host: Yeah. That makes a lot of sense. Talk to me a little bit about how your medical team goes about treating a major depressive disorder.

Muhammad Awais (“Awais”) Aftab, MD: So, the first step involves a comprehensive clinical evaluation. We have to get a good sense of what symptoms are present, in what sort of way, what are the contributing factors to that. Then, we also have to rule out other medical and psychiatric disorders. Depression is a symptom that can also be present in other conditions. Sometimes people can have a severe anxiety disorder that presents with depressive symptoms. Sometimes people can have substance use problems are making them feel depressed. Sometimes they may have dementia or other related disorders.

In a similar kind of way, sometimes there are medical problems that can present with depression too. If people have hormone deficiencies, like thyroid hormone deficiency, or they have certain vitamin deficiencies or other medical problems. So, thorough assessment is needed to roll out medical conditions as well as other psychiatric disorders that might better explain that. Once an evaluation has been done and it has been identified that this is a case of major depressive disorder, then we look at treatment options. And the two most common treatment modalities that we use are psychotherapy and medications, and both of them are well-studied and well-recognized forms of treatment for depression.

Usually, for milder cases of depression, psychotherapy alone can be sufficient in getting the people better and restoring their functioning, versus if a person has moderate to severe depression, the recommendation is to have a combination of medication and psychotherapy to better address the problem. And we have a number of different antidepressants and other medications available to treat depression. They often have similar degree of effect, but they can differ in the side effect profile. And so, that requires a discussion with the patient regarding what medications they may have tried in the past and what sort of preferences they might have regarding potential side effects. And based on that discussion, a suitable antidepressant can be prescribed.

Host: Okay. And in addition to some of those medications, are there any coping mechanisms or things that you have the patient do to help them on the road to recovery faster?

Muhammad Awais (“Awais”) Aftab, MD: A number of lifestyle factors can be quite helpful as well. I usually recommend exercise to all patients with depression. It seems counterintuitive because depressed people often lack the motivation, and they find it difficult to engage in that. But when people do have enough motivation, enough energy to be able to engage in exercise, they often experience significant benefit in their mood. I recommend at least three to four times, moderate intensity, aerobic activity or resistance training.

In addition, there's also evidence that dietary changes can be helpful as well, moving away from a highly processed foods and refined sugars to more whole grains and less refined food can have a positive impact on mood. Practices such as meditation, practices such as better sleep hygiene, more contact with nature, such as taking walks in the park, these are all things that can improve a person's mood. And social contact and social support is very important in this regard as well. Depressed people often have a tendency to withdraw themselves and isolate themselves. So, I encourage people to connect with their friends, to reach out to their family members and to discuss things with them because social interaction is a very powerful treatment modality.

Host: You know, someone might be listening to this for themselves or a loved one, and they might be wondering, like, "Hey, will I ever get out of this hole? Like, how long is this going to take?" Sure, I can do treatments and that lifestyle modification. What have you seen in terms of how long treatment takes and how fast someone might be able to rid themselves of this depression?

Muhammad Awais (“Awais”) Aftab, MD: There's a lot of variation to be honest. Everyone's response to treatment, both medication and psychotherapy varies quite a bit. There are some people who respond very well to medication. They start experiencing benefit within three to four weeks. I would say that happens, but that is less frequent. The more common scenario is that I see people improving and coming out of depression in a span of two to three months. That's the more common scenario. And then, there are some people about 15-20% of people who have more prolonged forms of depression and people who don't respond very well to standard treatments. And usually for them, depression tends to be an ongoing issue, and it can last months. So, there's a lot of variability. But generally, most people begin to feel considerably better in a span of two to three months.

Host: Okay, got it. Now, just as we close here, Dr. Aftab, I always like to ask a question around what is something that you wish more people knew about either major depressive disorder or just depression in general?

Muhammad Awais (“Awais”) Aftab, MD: One thing I think a lot of people don't recognize or don't fully appreciate is that depression is a part of our ordinary life as well. We experience difficulties in stressful moments, we feel down, we feel sad. And the many forms of depression that treat in the clinic, or that we recognize as clinical depression, exist on a continuum with this ordinary sadness. There isn't really a magical point at which ordinary life sadness or ordinary life kind of difficulties or ordinary life misery transforms into major depressive disorder or clinical depression. So, it's a continuum of severity, and there's a lot of gray area in between where it cannot be entirely clear whether the person has a clinical form of depression or not. So, it's not a categorically separate thing, but rather it's a continuum of depression of everyday difficulties at one end and very severe, very disabling depression at the other end with a lot of people residing somewhere in between.

And one recommendation that I often have for people with clinical depression is to not think of all anxiety and depression in a negative pathological manner, because these symptoms are telling us something about our lives as well. Oftentimes, when people feel depressed in certain life circumstances, that's an indication that something in their life has gone wrong. Maybe there are problems at work that need addressing. Maybe there are problems in their marriage or in their life, family circumstances that need addressing.

So just as bodily pain is a signal, that tells us that something has gone wrong and we need to address it. In the same kind of way, depression and anxiety can be signals that something has gone wrong in our lives, in our relationships. And psychotherapy and medication is helpful, but we also need to look for what it is in our life that has gone wrong, and how can we set it right.

Host: I think that's really well said. It really feels like we're all kind of riding the roller coaster of life and there's going to be ups and downs. And when you experience some of these feelings, it's an indication maybe that you may need to pay attention to some area in your life. But if it gets overwhelming, it's also really just assuring to know that there is help and that there is treatment. So, Dr. Aftab, I really appreciate your time. Thank you so much.

Muhammad Awais (“Awais”) Aftab, MD: Thanks so much for having me.

Host: To learn more about Southwest General Health Services, you can visit swgeneral.com and search behavioral health. If you found this episode to be helpful, please consider sharing us on your social channels and check out our full podcast library to find out topics of interest to you. My name is Prakash Chandran, and this has been a Southwest General Health Talk. Thanks.