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Introduction
Dr. Bob: And welcome to The Dr. Bob Show. Thank
you so much for taking your time to watch this show
to learn a little bit more about your health, how to
stay healthy and how to stay happy. Are you doing those
things that we recommend every week - exercising 20
minutes five, six, seven days a week, starting that
day off with eight hours of sleep? See how good it will
make you feel! Start the day off with a breakfast of
fruit and fiber and most of all, what is it we like?
It's laughter in your life. Find that loved one that
you talk with, that you tell funny stories to, that
you have a good time with and laugh a lot. Your immune
system will work better and you'll feel better.
Hello, I'm Dr. Robert Overholt and I'll be your host
for the next 30 minutes on The Dr. Bob Show. As I was
coming in to the show, I was singing a song, "Don't
know why there's no sun up in the sky"- it's a song
about depression. 17 million people in the United States
will have a major episode of depression this year. 25%
of women at sometime in their life will have a major
episode of depression. 12% of men will. We're going
to be talking about depression, how you can recognize
it because if we treat depression, some 80-90% of people
will get an outstanding response. I have an excellent
guest. My guest is Dr. Ken Jobson, board-certified psychiatrist,
and we'll be talking about depression. Later on in the
show, we'll be talking about how you can predict whether
you're going to have a heart attack or stroke. There
is a new study that will help you on that. We'll be
talking about abdominal pain. What parts of the tummy
do you need to be thinking about when you have certain
illnesses? So, we've got a lot to do. You'll want to
stay tuned. It's going to be a great show.
Dr. Bob: Depression is one of the most common
things that a primary care physician sees in private
practice. So many patients are depressed. 17 million
people in the United States will have a major episode
of depression this year and that's what we'll be talking
about with Dr. Ken Jobson. Ken, welcome to The Dr. Bob
Show.
Dr. Jobson: Thank you.
Dr. Bob: Tell me, you're a board-certified psychiatrist?
Dr. Jobson: Yes.
Dr. Bob: What is the training of a psychiatrist?
Dr. Jobson: Medical school, an internship, and
then three-year residency in psychiatry.
Dr. Bob: Now, you did your psychiatry training
where?
Dr. Jobson: Psychiatry at Chapel Hill, University
of North Carolina.
Dr. Bob: At Chapel Hill. Tell me about depression.
What is depression?
Dr. Jobson: Well, it can be a lot of different
things. It can be a mood state that's a response to
loss and be a normal response, or it can be an illness.
It can be a biologic condition where your mood and your
sleep and your energy and your appetite change and depression
becomes very dangerous under those circumstances.
Dr. Bob: Now, when somebody has a death in their
family and they have depression, do you call that depression?
Dr. Jobson: Well, grief is one way towards getting
depressed and staying depressed. Many people will pass
through their grief with support and time and do well
but that's grief. So grief is a depressed mood state
but not the illness depression.
Dr. Bob: When you look for classic signs of
depression, what are the classic signs that you see?
Dr. Jobson: Well, there are several categories
of depression but the most common would present with
a group of symptoms that would include insomnia (especially
awakening in the middle of the night), a decrease in
energy, sometimes an increase in irritability (often
the mood being worse in the morning), and a change in
appetite and weight.
Dr. Bob: Changes in pleasure?
Dr. Jobson: You almost lose the savoring of
life. The pleasures are lessened and hope is lessened.
Dr. Bob: That must be a terrible problem to
have and for the people that surround you to see you
going through.
Dr. Jobson: Most people who have had many medical
illnesses and also had depression say that the depression
was the worse experience they've had.
Dr. Bob: Wow, that's a very strong statement.
Let's talk about, when I hear the word depression, I
hear words going through my mind like, dysthymiac depression,
seasonal effective disorder, different kinds. Talk to
me about some of those.
Dr. Jobson: There are a number of categories
of depression. And it makes a lot of difference to get
the proper diagnosis and treatment. There is the type
of depression we just mentioned that is the classic
chemical depression. There are types of depression called
dysthymiac disorder that is somewhat of a lifelong mood
state. In the past we thought that was just their personality
or an unhappy childhood but, in fact, it's often a chemical
state that can be treated fairly straight-forwardly
with antidepressants. There's almost manic depressive
illness where the mood states go to the high side with
either an excessive kind of euphoria or irritability
on the high side and then bouts off serious depression.
Both the depression and the manic-depressive illness
carry a very high suicide rate. And then there are some
other depressions that people will often miss that sometimes
present as a change in cognition or thinking. It is
the presentation. Sometimes it's a chronic pain that's
been a puzzle despite many medical work-ups. At other
times, surprisingly, it's a type of irritability and
sort of displeasure in life that doesn't present classically
and yet is often responsive to treatment.
Dr. Bob: So sometimes people don't know they
can have these sort of vague symptoms of irritability,
mood swings-things like this-and may not really know
they've got depression.
Dr. Jobson: Most depression is not diagnosed
and most depression that is treated is not treated with
the full vigor and duration and full success that it
should be.
Dr. Bob: How about medical illnesses, medication,
certain illnesses that are the real cause of depression.
What are some of those?
Dr. Jobson: There are many. Almost any medical
illness carried to a severe duration increases the risk
for depression. Substance abuse increases the risk and
as you said, stressors, whether it be a medical stress
or multiple losses, increase the risk for depression.
Dr. Bob: So when you're taking a history, you
have to go into the medical problems. I'm thinking of
hypothyroidism, when somebody doesn't have energy and
they are just sort of sluggish, and somebody could think
they are depressed. How about medications?
Dr. Jobson: Well, there are many medications.
First, your example of thyroid disease is a classic
example of the endocrine state that dramatically increases
the risk for depression. With the medicine, some of
which are blood pressure medicines and some of them
hormones, there are many medicines that can cause depression.
And then substance abuse can cause depression.
Dr. Bob: So, the doctor that's just prescribing
medicines has to understand that some medicines in themselves
can make people feel crummy.
Dr. Jobson: Absolutely.
Dr. Bob: And removal of those medicines…does
medicine ever trigger off depression and that's the
trigger, and then you take the medicine away and the
depression stays on? Or usually when you withdraw the
medication does the depression go away?
Dr. Jobson: Either can happen, but your point
is well taken. Whether it be a medicine, whether it
be multiple losses, or whether it be an illness, the
stressor sometimes will trip or precipitate the depression
and then the depression may take on a life of its own.
Dr. Bob: I remember one patient who was on some
doses of cortisone-corticosteroids-and it gave this
person a manic and a depressive episode that persisted.
Dr. Jobson: Almost 20% of people that have moderate
to high doses of steroids end up with a depression of
some sort.
Dr. Bob: Now, let's talk about unipolar and
bipolar. What do those words mean? Are there two poles
in the head or what's going on?
Dr. Jobson: Unipolar refers to depression and
bipolar illness is bouts of recurrent depression and
bouts of the mood being either too high or too irritable.
With those highs or manic episodes, or hypomanic episodes,
the person may feel like they have less need for sleep
but they talk much more. They may do risky behaviors
they may not normally do. They may have a feeling as
if their thoughts are racing and they become very irritable
and insistent and intrusive in other people's lives.
Dr. Bob: So, there's a wide spectrum that we've
got. The treatment has to be different for all those
for everyone.
Dr. Jobson: It's very different. In fact, with
manic depressive illness there has been more change
in the treatment and in fact, the diagnosis and treatment,
of manic depressive illness in the last three years
than any psychiatric illness treatment in the last decade.
Dr. Bob: And that's what I would like to talk
about when we come back. We'll be talking about what
is the treatment for bipolar or some of the other types
of depression. Have you been depressed? Have you been
afraid to tell your doctor about it? You know, we'll
talk about depression being an illness, a tough illness.
Don't be embarrassed about depression. Get your treatment.
80-90% of people respond beautifully. Wouldn't that
be great?
Dr. Bob: We're talking with Dr. Ken Jobson,
board-certified psychiatrist. We're talking about depression.
Depression in cardiovascular disease, diseases of the
heart, people that have heart surgery frequently…when
they recover they have a great episode of depression
that's really overlooked because of the seriousness
of the surgery. Another study showed that people with
depression have a high incidence of heart attacks and
so, depression can be the cause or effect of those.
Dr. Jobson, when you see somebody that's got bipolar
disease, what problems do you see with them? What's
the end result, sometimes?
Dr. Jobson: Well, 1 in 6 end up with completed
suicide-death by suicide.
Dr. Bob: That's…that's astronomical! That's
really a mind-blowing…
Dr. Jobson: Well, especially since it's treatable
and it often goes undiagnosed and untreated. But, you
asked what we see with it? We see the ravages in their
lives; we often see the ravages in their families and
in their careers. They have bouts of recurrent depression
that often come on from early life. They have multiple
bouts of depression and in between they have other types
of cycling of mood that can be destructive to them,
all the way from the severe type of obvious manic illness
where there is grandiosity and little sleep and they
end up with hospitalizations. But unfortunately, there
is a lot of bipolar illness missed that's more subtle,
where the highs or lows could be diagnosed but may be
missed for years and years.
Dr. Bob: When somebody has bipolar manic depressive
disease, does either one of those dominate the person?
Is it usually the manic or the …?
Dr. Jobson: It can be either. The pattern of
how much depression and how much mania, along with the
frequency of cycling, dramatically change how you treat
the illness.
Dr. Bob: For instance, let's talk about the
treatment of this, or tell me some of the recent changes
and understanding of bipolar disease.
Dr. Jobson: Well, first the diagnosis of manic-depressive
illness. There has been the recognition that we were
missing the majority of manic depressive illness in
the subtle forms where the highs are periods of talking
more than usual, impulsive travel or spending, or risk
taking behavior that the person normally wouldn't do,
a rapid speech, rapid thoughts, less need for sleep.
But the treatment for bipolar disorder is again dramatically
different than it is for standard depression. One of
the things that you must do is regulate sleep. That
timekeeper must be regulated-the amount of sleep and
the timing of sleep. The other is, there need to be
contingency plans and flag symptoms to note when it
comes on and what to do at the beginning of the episode.
A third is that the actual medicines used for manic-depressive
illness have dramatically changed the last two to three
years. And then the scales or monitoring devices-how
you help the patient and the physician monitor the progress
and its loss of change.
Dr. Bob: Well, let's talk about if you make
the diagnosis, if somebody picks up the fact that somebody
is manic all over the place and then gets depressed
all over the place and its obvious what they've got…
or somebody who is smart that picks up these subtle
signs, too much risk taking and then coming down with
the blues a lot…how do you start treatment?
Dr. Jobson: Well, first you educate the patient
and preferably the family about that's going on. You
eliminate those things that might be making it worse.
Sometimes its medicines, sometimes its alcohol. You
regulate the sleep and you use mood-stabilizing agents.
And one of the problems we see is often people are given
just anti-depressants and anti-depressants can increase
the cycling rate of manic-depressive illness.
Dr. Bob: Wow! What type of anti-depressants
can increase the cycling? That's scary.
Dr. Jobson: Well, most of them can. Initially the old
tri-cyclic anti-depressants can, but any of the anti-depressants
are capable of increasing the cycling rate. That's not
to say they're not used in manic-depressive illness,
but they are best used when co-prescribed with mood
stabilizing agents. In the past we just had Lithium
but now we have many of them. We have Lithium and Depakote
and various congeners of Tegretol, Lamictal, Topomax,
calcium channel-blockers, and many other things that
will stabilize mood. It also depends on, again, the
frequency of cycling, the severity of the cycling, and
then where in the treatment cascade or algorithm-that
is to say, the guidelines or algorithms where they are
in their past treatment.
Dr. Bob: Now, if I'm a person on a certain medication
and I start recognizing (or my family recognizes) that
I am becoming manic, what do you add on to that? What
mood changer do you add?
Dr. Jobson: Well, first you check to see or
monitor whether they're getting enough of the mood-stabilizing
agent they have. Then you look at sleep and you do something
that acutely lessens the hypomania (or the mania) and
sometimes there are medicines called atypical neuroleptics,
things like Zyprexa, and other times you increase the
amount of the mood-stabilizing agent that's already
being used.
Dr. Bob: So it's really a very complex and a
very complicated and individualized treatment and disease.
Is that correct?
Dr. Jobson: Very much so and with the help of
the patient, or sometimes the family, it's very exciting
to treat because it's so successful now.
Dr. Bob: Let's drop back to the unipolar chemical
problems-somebody that's just got depression, somebody
that's in deep depression-when they wake up in the morning
they feel worse than when they went to bed. Tell me
about that. How do you treat that person?
Dr. Jobson: You educate them. You make sure
that they're not doing anything that makes it worse
and you typically use an anti-depressant. Now, psychotherapy
may play a part in this. It may play a big part, but
anti-depressants can be dramatically changing and life
saving. And when you use the anti-depressant, you want
to go not just for improvement in mood but resolution
of the syndrome and that makes a great deal of difference.
Often people will be taking an anti-depressant for years
and be improved but not be asymptomatic.
Dr. Bob: And so, you really strive for an asymptomatic
state. I want to ask you a tough question but an easy
question for you. Do you want to use tri-cyclics, the
Elavils, or do you want to use some of the SSRI's like
Zoloft or some of those?
Dr. Jobson: There are seven families of anti-depressants.
We hardly ever use the tri-cyclics anymore because of
medical risk. The Prozac family (and there are many
in that family now) is just one of the other newer forms-there
are many different types of anti-depressants now.
Dr. Bob: Isn't that wonderful that the pharmaceutical
industries give you this choice of so many medications
for such a tough illness? What's your advice to somebody
that's got depression or to the family of somebody that
knows somebody is depressed and is not seeking treatment?
Dr. Jobson: Learn a lot about depression; get
treatment and be sure you get monitoring and follow-up
over the long run for the status of your mood.
Dr. Bob: Ken Jobson, I want to thank you and
I'm sorry we've run out of time. I have found this most
interesting and most informative and most important.
And a lot of people are going to be depressed this year
and they're going to have to get treatment.
Dr. Jobson: Thanks Bob.
Dr. Bob: And we're going to be coming back and
we'll be talking about how do you tell if you are at
risk for a heart attack or even a stroke? And abdominal
pain-what is serious and what's not serious? And how
do you know if you have appendicitis or gallbladder
disease or pancreatitis or the things that are in your
abdomen? You'll want to stay tuned. We're going to try
to get all of that in a little bit of time.
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