Caitlin Whyte (Host): Depression and mood disorders
can make it difficult to live a happy, productive life. Find out how one of the
state's largest comprehensive hospital based behavioral health programs is
offering new hope to patients with life affecting mood disorders. Dr. Sal
Savatta joins us today to talk about your options with Trinitas. He is the
Chair of Behavioral Health and Psychiatry. This is Trinitas Health Chat, the
official podcast of Trinitas Regional Medical Center. I'm your host, Caitlin
Whyte. Doctor, let's talk about treatment first. What are some newer options we
might not know about for those dealing with depression and mood disorders?

Sal Savatta, MD (Guest): There are a lot of options
available. But newer, we're probably talking about the scope of years, not
months. The only thing that's truly new in the last year and a half that wasn't
available before, was esketamine, which is an intra-nasal form of ketamine. And
ketamine has been thought to be effective in treating depression for years. And
there've always been small scale studies of IV infused ketamine, which is something
that's given through an intravenous line. And those studies were always small
scale and they were always kind of short bearing results and they were always
with different protocols. So, it was something that was, although some
psychiatrists did adopt it, it was never available wide scale. It was never
reimbursed by insurance because it wasn't a standardized FDA approved
treatment.

And intra-nasal esketamine is kind of analogous in that it's
the same basic compound, but it's given through nasal spray and that was tested
in a way that could gain FDA approval. And it was shown to be very efficacious
and in people who had tried some treatment for depression, which is a medicine
like a traditional antidepressant, which is a pill and they didn't fully respond
to that pill. When usually it's, at least you have to take one pill, not
respond, take a second pill. And then while you're on that second pill the
esketamine can be added to it. So, that's kind of one of the newer treatments
that's available and it's, you know, it's hasn't been shown widespread use yet
just because when things are new, it takes a long time for treatment programs
and you know, to arise and psychiatrists to kind of incorporate that into their
practice. That's one of the treatments for depression.

One of the things that is actually very old, it's about 70
years old, where you're starting to see a resurgence and something that we're
offering again here at Trinitas is electroconvulsive therapy. And that's
something that has a lot of stigma attached to it. It's been portrayed in the
movies in very negative fashion and the movie portrayals for the most part,are
not related to anything that you would actually use it for in psychiatric
treatment. It's a procedure that's done voluntarily where the patient gets
general anesthesia and is asleep when they get the treatment.

But in the movies, it's also, it's often shown as something
that's forced upon someone while they're still awake. So, it's really, you
know, it's really not like that at all. And it was never like that at all, but
the things that historically has been a major problem with it is that there's
usually some type of memory loss or a memory problem associated with the
treatment and in the last 20 years or so, we've kind of really refined the
protocol. So, that memory loss is still common during ECT, but it's usually not
treatment limiting. And many of the patients that got adequate treatment for
depression report some short-term memory loss, but then it comes back after
several months and you know, they're actually very happy with the treatment and
that's something that was much more effective in general, in terms of
percentages, much more people who get ECT, tend to respond to that by
percentage, as opposed to people who just take a regular antidepressant pill.

Host: Now, when we say depression and mood disorders,
are these the same thing? Are they different? Tell us about the conditions.

Dr. Savatta: Mood disorders in general are something
that affect one's mood and depression falls under that category. So, major
depressive disorder is the most common mood disorder that we psychiatrists
treat. And that's basically a syndrome where someone is sad and they have low
energy and they have bad concentration and their appetite is affected. They generally
lose weight, but sometimes they overeat and gain weight and they don't have
interest in doing things. They have difficulty experiencing joy, they feel
guilty. They may feel hopeless that life will never get better. They may feel
like they, they want to die or may actually think about committing suicide. And
in some occasions, they actually make attempts or may complete that without
treatment. So, it's a very serious disorder, but it's not just feeling sad.
It's a constellation of symptoms and we psychiatrists considered major
depressive disorder, when at least five of those symptoms are present for at
least two weeks. And they don't have to be present 24 hours a day for two
weeks, but more often than not over two weeks. And so that's major depressive
disorder and that's the most common mood disorders, something approximately
before COVID, about 7% of the US population was suffering from a major
depressive disorder at any one time. If you did, if you just pulled a hundred
people on average, if you had a random sample, it would be seven people were
suffering. Now with COVID, my guess is it's a lot more, I haven't seen a more
recent number, but you know, I think all of us are feeling it.

And when we can imagine that one would be more likely to
have that clinical syndrome so that, you know, that's major depressive
disorder. So ,now there are other mood disorders as well, and the most common
other mood disorder, which is much less common than major depressive disorder,
is bipolar disorder. And bipolar disorder is like it sounds there's that
depression and that depression is just like, it is a major depressive disorder.
But at other times, the patients are the opposite of depressed. They have high
energy, they are feeling maybe happier. They don't need to sleep much because
their energy is so high. They may only sleep a couple hours a night and they
start talking really fast and they get distracted very easily and they may be
what we call a grandiose, willing to take on extremely large plans that are
impossible for them to complete.

And there more extreme versions where that is something that
actually it's kind of accurate as the way you would see it on a movie where
someone were to become delusional or like believe things that are not true.
Like they have a lot of money and they have millions of dollars or they're the
Messiah. So, really like really profound grandiose delusions can happen in
bipolar disorder, but only a small percentage of bipolar people with bipolar
disorder experience that. Most people are just kind of more energetic. As
another person who is not trained in this could tell that they're not exactly
right, but they wouldn't think that there's something psychiatrically wrong
with them.

And so that's kind of the other major mood disorder, which is
a bipolar disorder. And there is some small percentage of people with bipolar
disorder who have elements of this high energy and grandiosity, or maybe not
grandiosity, but high energy and distractability and increased in goal-oriented
activity and at the same time be depressed. And that's called the mixed mood
disorder. And actually that's a very dangerous state because many people who
are depressed, don't actually attempt to harm themselves because they're have
so low energy. And they're so withdrawn that even to mount an attempt would be
something difficult for them to do, but people who have a mixed mood disorder,
they're simultaneously feeling terrible while having a lot of energy. And we
consider that a very dangerous state in psychiatry.

Host: Whenever we talk mental health, it's important
to talk about the stigma around it. How have you seen the way people talk about
and address mental illness change in recent years?

Dr. Savatta: So I, I can definitely say that I've
been practicing now, I'm almost ashamed to admit it, because it means I'm
getting older, but a little bit more than 15 years, between 15 and 20 years,
depending on various forms of training and in the last 20 years, the stigma has
definitely dropped in that a lot more people are willing to come into treatment
as compared to 20 years ago.

And from what I read in the history books as compared to 40
years ago, 50 years ago, and people are a lot more willing to talk about it.
But because the stigma has reduced doesn't mean that it's gone away. And in
many ways it's just changed. People are still stigmatized and they still feel
bad and feel less because they suffer from an illness and they're just more
inclined to come to treatment, but there's also a lot of that stigma may
interfere with treatment in that they may give it a short try, and then, you
know, they may kind of then realize they're in treatment and say, well, I don't
want to do this anymore and just drop out prematurely.

The other thing is that, you know, we in mental health
typically think as a family member being a support for a patient and it's often
interesting to see that the non-affected person may have a very strong stigma
towards treatment for mental illness and may actually stop their family member
from getting treatment. So, this is not a common thing, or it is a common
thing, but you know, it's something that you can't just expect. You really have
to know the situation, but there are definitely a lot of people who feel like
they need to hide their treatment from others. Feel like they need to hide that
fact they take medication from others.

And even from people who are very close to them and would
normally be supportive. So, it's definitely gotten a lot better, but we
definitely have a long way to go. And even people who acknowledge, who mental
illness may still have a stigma towards it. And it's still kind of an us versus
them phenomenon. It's like, well, I don't, I'm not one of those people, but the
reality is we are one of those people, all of us are at risk for mental illness.
If you put enough stress on someone, then they are likely to incur one of these
disorders. Now, some people don't require very much stress to got there and
some people require a lot of stress to get there, but you know, this is
something that every human is susceptible to. There's not an us versus them.
It's you know, we're all at risk. And so there's, you know, we shouldn't view
it in that way.

Host: For some, medication is an option to pursue,
but it can be a difficult one. Why does it sometimes take so many tries to find
the correct medication for a patient?

Dr. Savatta: There are reasons that we are fully
aware of. And then there were reasons that we're not fully aware of in the
sense that, you know, we don't know enough about what's going on at the
molecular level in the brain to say that you are going to respond to this
medicine, for sure versus you're not going to respond to this medicine for
sure.

And like one of the things that we psychiatrists, you don't
hear psychiatrists say that it's a chemical imbalance in someone's brain, but
you do hear a lot of laypeople say it's a chemical imbalance in someone's
brain. And that's kind of like an oversimplification of what we understand.
Like, in the sense that I can tell you if I modify your serotonin pathways and
give you things that are serotonin analogs or boost serotonin, you're likely to
become less depressed, but then the next inference is all your serotonin
depleted and you have a chemical imbalance and I don't really know that. I just
know that augmenting your serotonin makes you less depressed. Do you have a
serotonin deficiency? I don't know that. I mean, we don't have that level of
information. I mean, we do know like dopamine, norepinephrine and serotonin are
the three principle neuro-transmitters involved in depression.

So, we target those with our medicines and various
medicines, the traditional medicines will target those. Some of our newer
medicines actually work on different pathways and a drug like esketamine works
on glutamate pathways, which is a relatively new neuro-transmitter thought to
be involved in depression. It's still, we've been doing it for 30 years. But
now that we have a treatment, it's kind of more convincing that we're onto the
right track. So, you know, part of it is there's a lot of different medicines.
There's a lot of different pathways. There's a lot of ways to target the brain
in terms of treating the depression, not knowing exactly how someone is truly,
you know, needs to be modulated until we try a medicine, is kind of what makes
it difficult. Like most people respond to serotonin serotonergic medications,
but not all will, but we won't really have a way to test the brain until we can
go ahead and try that medicine and see if they are likely to respond. So,
that's you know, part of it is the, it's still murky exactly what's on the
brain.

Another part of it is when someone takes a medicine, their
liver processes these medicines, and some people have livers that, that
process, the medicines very efficiently and you give them a large dose of
medicine and the brain sees very little of it. Whereas other people have livers
that process the medicine very slowly. And if you give them a normal dose of
medicine, the brain sees a lot of it. And that might be okay for treatment, but
then they may get side effects. Like they, they may get too tired or they may
get drowsy. They may feel like they have a tremor or have some other side
effect associated with these medicines.

So, there are more complicated, but the more simple answer
is there's things going on in the brain that we don't fully understand. And
there's things going on in the liver that even when we kind of straightforward
what's going on in the brain, something would work, how someone processes the
medicines can change and all these medicines are processed similarly, but
slightly different. And all these medicines work similarly, but slightly
different with respect to neuro-transmitters. So, it's really more of a matter
of finding the medicine that is most likely to work for that individual based
on what, how they metabolize the drug and how their brain is likely to respond.
Then also along with this is the side effects that they don't experience too
many side effects.

So, you know, it's a complicated answer. Psychiatrists can
do well with a lot of patients, but there's not a medicine for everyone. And I
say this because, you know, our studies show that a lot of people given a lot
of different medicines never respond to any of the traditional medicines.

Host: Now tell us a bit about all the components of
behavioral health treatment and how they work together from yoga to meditation.

Dr. Savatta: So, and that's completely correct. And
one of the things that you know, I like to tell my patients is they should try
everything that's appropriate for them. One of the things I get commonly as
someone who's new to psychiatric care and I recommend the medicine and they
say, well, can't I just do yoga?

Well, I want you to do the yoga. Can't I just modify my
diet? Well, I want you to modify your diet. he is like I drink a little bit. Is
that a problem? Yeah, I want you to stop drinking altogether, even if it's
within an acceptable level that you don't have an alcohol problem, but it's
definitely going to be easier if you get over depression.

But, you know, I want you to take the medicine too. So, the
reality is mild to moderate depression, and especially mild depression tends to
respond better with things like yoga and diet modification, other forms of
exercise treatment than they do medicines because the medicines tend to have
more side effects than these modifications. And for someone who's mildly
depressed, these modifications might actually be enough. Whereas if someone has
moderate depression, those modifications can help. But there's a strong
likelihood that they're not going to be enough and they may progress and become
even more depressed and become severely depressed.

And once severely depressed, that is like the type of person
I was talking about initially, where they're unable to experience even basic
things that the normal person could experience. They're so withdrawn, I mean,
they didn't have a shower for days. They may not eat at all. It may become a
health risk that their hygiene and their poor nutrition may be health risks.

So, someone like that is not going to exercise their way out
of depression. So, there are a lot of different things and psychotherapy does
play into this. Psychotherapy is an excellent treatment for mild depression and
even moderate depression. Like when you start to look at studies that compare
the two mild to moderate depression, if you use medication or psychotherapy,
but not both, they're about equivalent and usually about 30 to 40% get better,
maybe even 40% or 45%.

But if you combine the two, then you're kind of in that 55
to 60% range get better. So, there are a lot of different ways to, to get
better. There are a lot of ways, healthy living really does work. Watching what
time do you go to sleep? Making sure you get adequate sleep is an excellent
preventative measure, to make sure that you don't suffer from depression.

And if you are suffering depression and smiled, you can do
all these things. And it's often enough, but those people tend not to come see
a psychiatrist. They may see their primary care doctor, you know as part of a
visit or they may say, well, you know, let me just talk to my primary care
doctor, but for the people who go through the trouble of finding a
psychiatrist, making an appointment and showing up to that appointment, they're
usually moderate. They usually not mild. And so usually that moderate person,
who's going to be amenable to some type of medication therapy or, you know, at
least the discussion needs to be had, then we decide, well, I'm going to do all
the lifestyle modifications that make sense. I'm going to start meditating on
top of everything you said, and I'm going to go to psychotherapy once a week.

And let me try that first. And if that is what a person
decides to do, that is completely acceptable from a psychiatrist standpoint.
It's just, they need to know the options that are available to them before they
dismiss them.

Host: I would love to go back and learn more about
ECT, what it is and how it's making a comeback.

Dr. Savatta: So, electroconvulsive therapy or, you
know, abbreviated ECT, and which I actually learned recently from some of the
older doctors on my staff who have been practicing for 50 years, used to be
called electroshock therapy when they were in medical school. So, and that was
in the seventies or eighties in, ah, more like the sixties and seventies.

So, electroshock therapy is now called electroconvulsive
therapy. If anyone's still hears that term, it's not something that you see in
modern medical textbooks. But the goal of ECT is to place the person under
anesthesia and deliver an electrical current that causes a seizure. And we know
from before ECT existed, that people who suffered from depression and seizure
disorders tended to be less depressed in the, in the days after they had a
seizure and then their depression would come back and people, doctors noted
this. So, they said, well, if we can induce a seizure, then this could be an
effective treatment. And they tried using medicines and other things to induce
seizures. And it turns out it was very dangerous and not an effective form of
treatment.

And then, you know, doctors came with the idea, well, if we
use an electrical current to induce a seizure, maybe we can do this safely. And
maybe we can get the benefit that we've seen, where people just have seizures
when they're depressed. And in low and behold, they did do that. And they
started treating people with electrical convulsive therapy and saw improvement.
Over time, this has been modified that in the sense that it's still the same
physiologic principles, but anesthesia has been refined. And the way we deliver
the energy has been refined. And we can now treat people very effectively for
their depression by delivering this modality. Now it does have side effects in
that the most common one is memory loss. And most people who have ECT
experience some type of element of memory loss around the time of the
treatment. So, usually it's a three-day a week initially, Monday, Wednesday,
Friday, and they usually people get it between eight and 12 sessions. And then
by then, many people are in remission or close to remission.

And if they're close to remission, they might get more
treatments in that same timeframe, and then they it can get either stopped and
they can get some other form of treatment for their depression, or it can get
continued on a less frequent basis. It's kind of complicated or it's kind of
lengthy rather than not complicated why one would get the other, and it really
has much to do with, if someone is trying ECT because they've failed so many
other treatments, then the likelihood of them responding to another treatment
ECT is no greater. So, they would probably want to continue ECT for a prolonged
period of time.

Whereas if someone was profoundly depressed and at risk from
their depression, and we see that in mental health where people take so little
care of themselves and are so withdrawn that literally they, they lose the
ability to think or interact. And that could be a very dangerous state. So, a
person like that might get ECT because it's the most, our most effective
treatment and tends to work very quickly within four to six sessions. They're
participating in their care and they're eating on their own and they're
showering again. So, it's really like, it's really amazing to see someone
benefit in this way. Someone like that though, they may have been not been refracted.
They may not have tried a lot of other treatments and it may be reasonable to
say, well, let's stop the ECT and let's go back to just medicine because now
that you're feeling better enough, and these medicines, which takes weeks to
sometimes months to work might be appropriate for you when they weren't, when
you needed this kind of rapid response.

Host: Wrapping up here, even with all of this great
information, it can be hard to make that first step and tell your doctor, or
begin the search for a therapist, but just remind us why it's so, so important
to start.

Dr. Savatta: The most important reason to start is
that one need not be anxious, that they're going to wind up someplace that a
treatment will be forced on them that is not indicated for them. So, anyone, if
they're kind of curious and they're not sure, I would say, err on, go ahead
and, and trying treatment and again, if you're thinking that it's a bad idea to
start treatment it's because you're under the influence of stigma. It's not
rational. If you're someone who could be suffering from something, why wouldn't
you go to a specialist who could potentially help you? Right? We don't worry
about this. Like, well, if I think I might have cancer, I will go to a cancer
specialist to make sure I don't have cancer.

You know, there's no stigma for getting cancer treatment.
But for mental health treatment, well what if I go over there and I think that
I might have mental illness, when I really don't have it. And that's not a
realistic concern. If you go there to be evaluated, a professional is going to
do a competent evaluation and is going to tell you whether you meet criteria
for any of the disorders and is going to give you choices on instituting an
appropriate treatment for that disorder. It's the same in every area of
medicine and the same in mental health. You know, we talk to someone, we do an
evaluation and then we determine if there's a treatment that can help them. And
then we give them options and that's all that happens in mental health
treatment.

So, really it's nothing to be afraid of. There's no downside
to being evaluated. Now someone may go and they may have treatment and they may
have extended treatment. And they may say that I don't feel a lot better, even
though I've had treatment and that can happen depending on the type of
treatment or depending on the type of illness. But so there is no guarantee of
success, but there is, you know, there is at least someone should at least go
through the trouble of figuring out if there's a potential for success. So, I
do think it's very important for people to just kind of be open to the idea of
if someone can help me. Then I should try that.

And it's kind of just general advice. If you can go
somewhere and be helped, why would you go through struggling and suffering and
not take advantage of that help? And that seems to be something with mental
illness that people they're like, oh, that's a good idea. I should struggle and
suffer and not take advantage of help because it means I'm less if I get help.
Yeah. Uh, and again, I know of very few things that this applies to, and the
other problem is own may serve, you know? Oh, the is knocking and pinging.
Should I get the car fixed? Well, I don't want to know. It's just really a
unique thing about mental health that we feel less if we get help. Whereas in
other areas, it's just fine.

So, you know, it's natural. I mean, believe me, if I was not
in this field, I would probably feel the same way. Part of our training as
psychiatrists, psychologists is to get to a point where we recognize those
biases in ourselves. And so, we can overcome them so that we could truly be
helpful to our patients. So, it's a very natural feeling and it's pervasive.
But it's not a logical feeling. If you apply logic to the situation, you would
say, let me take the opportunity to see if I can benefit. And then like any
other condition in medicine, failure to get help in the beginning can often
lead to more severe problems and more difficult treatments and more, more
suffering if you wait until it's late in the game.

So, certainly, you know, people who go on to attempt suicide
and commit suicide, most of them never sought help, about half of the people
never sought help. And of the people who did seek help, the most common thing
is that they dropped out of help. And it's more than 90 days since they last
saw of mental health professional.

So, it's really important to kind of be treated as, as best
as possible. And usually that's as early as possible when you qualify for a
disorder in the sense that if someone comes in and they're well, a psychiatrist
is more than happy to say, listen, you're maybe sad, but you don't meet
criteria for a disorder that, that we would diagnose. And therefore we're not
recommending other treatment other than maybe just general lifestyle
modifications that are appropriate to every individual, but you don't have a
disorder and therefore you don't need a quote unquote treatment. So, you know,
it's really, it's just to just to be kind of proactive in health maintenance
and look at it that way, rather than thinking that there's something wrong for
being evaluated and getting treated.

Host: Well, thank you Doctor for all you do. And
thank you for listening to Trinitas Health Chat. To find out more about how
Trinitas Regional Medical Center can take care of you, visit Trinitasrmc.org.
Let our highly skilled and compassionate staff help you or a loved one today by
calling 908-994-7552. That's (908) 994-7552.

Trinitas Health Chat is the official podcast of Trinitas
Regional Medical Center. I'm Caitlin Whyte. We'll see you next time.