Taarika Foundation (TF):
My name is Sania, and today I have with me Dr. Vidhya Krishnan, who is a child psychiatrist. We will be talking about the treatment of depression using biopsychosocial interventions.
Before we do that however, would you like to introduce yourself, Dr. Krishnan?
Dr. Krishnan (DK): Sure. Thank you, Sania, for having me today. As you already mentioned, I’m Dr. Krishnan and I’m a child and adolescent psychiatrist. For my day job, I work at the Children’s Health Council in Palo Alto where I’m the head of adolescent mental health services.
What are the different ways you treat depression?
DK: So depression obviously is a mental health condition. It is the language we use for the condition called major depressive disorder, and a few other depressive conditions. Whenever we try to address a mental health condition, we try to come at it from very, very different directions.
So, we try to address the biology of the condition which is what is happening from a chemical, neurocircuitry kind of a standpoint, and psychological, which is the way the brain thinks and processes information, and then we come at it from a social standpoint, but I want to include that to say both social and environmental.
The reason I break it up into these three parts is because [the biological umbrella includes interventions like medication]. The psychological part would be therapy. The various kinds of therapies one might use includes “talk therapy,” one of the more popular kinds.
[However] there are other kinds of therapies people use to treat depression [that address] the social or the environmental factors include things that people do: what’s happening in school, and in a person’s family life, friend circle, even things we do on a daily basis, what we eat, how we sleep, the level of activity we do. So what I would like to say is overall, the treatment of depression includes a wide umbrella of things that basically touches every aspect of a person’s existence.
TF: That’s incredibly interesting to know. I knew that there was therapy and medication, but I didn’t realize that there was such a wide variety of ways that depression was treated. And so that leads me to my next question, which is,
When do you recommend a child’s depression be treated with medication in terms of their age and severity?
DK: So as far as the age goes, there is no particular cutoff. […] There’s not an age below at which we will not treat depression and there is not an age above which we will not treat depression. So I think the question, most importantly, is what presents in front of you. I think of two big categories when I bring up the idea of using medication to treat depression with my clients and their families.
One of them is the severity of the depression. If someone has what we would like to call a moderate to severe level of depression, medications automatically enter the conversation. Just because we talk about it doesn’t mean we always do it, but that definitely shows that things are sever enough that it should be talked about.
The other big factor is functional impairment, right? The way a child goes to the world, they have a family component of their life, a school component of their life, and a social component of their life. If the depression [has progressed] to a point where it’s affecting all or some of these aspects to a big degree where a child’s ability to engage with their school, which is their main job, or their family or their friends is impacted in a big way, we do consider the possibility of medications as one of the things we might want to do to help them get back on a sound footing in their life. So I would say severity and functionality are the two main criteria I use when making medication recommendations.
TF: So that’s very interesting. I didn’t realize that there is no age limit or age range in which it should be treated with medication, so thank you so much for telling us that. And I’ve also seen a lot of people with depression, that see therapists and take medication, but I never really understood how exactly the medication helps with depression.
So can you explain what medications do and why simply going to a therapist isn’t enough in some cases?
DK: For a combination of reasons! Depression, obviously, is a sum of many different factors, right? There is genetic vulnerability, on top of which, there could be medical conditions or life circumstances, which conspire with each other to basically tilt the needle towards the person’s emotional health responding through depression, sometimes in triggered situations where there are negative life situations. Either within someone’s control or not, but sometimes depression can happen for no reason at all. Due respect to why a person becomes depressed at a particular point, there always are neurochemical and neurocircuitry kinds of changes that are observable in the brain, that is easily discernible through PET scan and various other functional metrics of analysis.
Like if you took a picture of someone’s brain who’s depressed, you can see that the various cells in the brain are not talking to each other as well as the like for them to, and the various parts of the brain also, at a bigger level, are not communicating with each other as effectively or efficiently as we’d like to.
And this is obviously a very big challenge because that is a big barrier to being able to experience benefit[s of treatment]; If you think of therapy, [it] is learning new ways of teaching someone new ways for the brain to deal with the world outside of themselves, or even in the way that we talk to ourselves inside of our head as we get prepared to deal with life or life’s circumstances.
The trouble is that when you have therapy alone and the level of depression is extremely significant, these large parts of your mind are not exactly working the way they’re supposed to. Even if the right kind of therapy is available, the barrier because of this lack of appropriate communication between the various parts of the brain is [such a barrier] that therapy alone cannot [provide sufficient support]. It’s almost like asking someone to jump over a wall that’s way too tall—it’s not possible to do no matter how much coaching or training you get. Sometimes you just need that ladder*. (*Note from TF: …and that’s okay!)
Sometimes medicine, if you think about it, is that ladder that you use to be able to climb over taller walls. Someone can coach you on how to climb the ladder, how quickly you can climb it, and how easily you can get over the top. But if you think about it that’s kind of the role it does it makes these parts of the brain have the chemicals necessary in the tank to be able to be available when the right messages come in, so the message is able to go through but also the same time allows for these various parts of the brain to talk to each other a lot more efficiently. It’s almost like it greases the wheels.
TF: That makes a lot of sense, so medicine is kind of like a booster that can really help you get out of your depressive phase or kind of, you know, ease your depression. And so, the next question is,
Once one of your patients starts taking medicine for depression, how long do they need to take it to see results and when would you eventually stop or taper down on the medication?
DK: So the medications, because of what I just explained as what the medications need to do, create this tank of chemicals that needs to be there in your brain so that, you know, […] various parts of the brain are able to communicate with each other more effectively. But eventually, the job of the medicine is to help the body build its own tank of chemicals. And for these effective communication roles that you have developed, almost like information superhighways, to kind of work of their own volition without the aid of medications. What ends up happening though, is this whole process of the brain becoming self-sufficient without the need of this external booster, like you said Sania, […] it takes the brain a while to get into this new habit if you will.
So number one, for the medicine to just start working to build the original time, it can take anywhere from four to six weeks, which is a long period of time and I understand. But given how long [treatment sometimes lasts], six weeks in that scheme of things does not feel like a large amount of time. But once we have found that the medicine is helpful or effective, the treatment of what we call an episode of depression needs to usually last somewhere in the order of about nine months to a year or a year and a half.
The reason for it is it takes that long to shore up the body’s defenses to undo some of the problems that have happened because of the brain being in a depressed place because certain parts of the brain to grow it the way they’re supposed to. It’s almost the same way you think of is you know when a child’s body is malnourished, they don’t grow tall, they don’t put on weight, their body is not able to do the various age-related tasks its due. Similarly a brain that is under the influence of depression doesn’t grow the way it’s supposed to grow and doesn’t do all the tasks and activities that it’s supposed to do for that age and stage of life. So you need to have that regrowth and that catch-up happens before you’re able to get out of that episode of depression. And that takes time, which explains the nine months to a year, year and a half timeline.
One of the things I always talk about is the window of time that we are using medications to address the symptoms of depression. It’s a great period of time to kind of combine that with the therapy because as the brain is growing back, like I said developmentally catching up, right, because depression has almost been like a pause button. What is happening is therapy added in at that particular point can accelerate that process significantly. So to be able to successfully get to that year mark are nine months or a year and a half mark and be at a place of readiness to be able to stop the medicines requires the person to be able to have caught up and keep up with all the things that have happened in that particular time and so I would say three things right?
Giving the brain enough time and space to do the growing it needs and the catching up it needs to do but also modifying the various thinking changes that have happened because of depression by the combination of therapy, is what gets somebody to a place of readiness to see both results and be at a place where you’re ready to stop the medications and kind of move on from that phase of treatment.
Though one other other point it would be useful to add here is that everything that I said right now is valid when you’re looking at someone in their first episode of depression or for the first instance of treatment. But it is important to remember that not everybody responds to the first medicine or the first treatment they take.
And not everybody’s in the first episode of depression. Sometimes this is maybe the second time or the third time someone’s struggling. But in those instances, the answer is a lot more customized and it is something that one should discuss with one’s doctors because once you get into further episodes of depression or more longer duration of illness, other variables start to matter in terms of how long it takes to see results or when a person is ready to stop [treatment].
TF: Yeah, that makes a lot of sense. I like how you said that that it’s, you know, it’s not like a one-size-fits-all type of thing, right? Not all patients will respond to the same medication the same way. And I think it’s really important for people to know that just because the first one didn’t work doesn’t mean the ones after that won’t work, you know?
TF: And so my last question to you is, just to tangent off of that,
How do you deal with suicidal thoughts or tendencies of patients that have depression?
DK: So one way to think about it is, at least as far as people with depression or concern, you want to think of suicidal thoughts or suicidal tendencies as a part of the depressive profile if you will, right. For many kids and including adults, it flows from the symptoms of depression in the sense that “I don’t feel like my life was worth living, I don’t feel like I’m able to help myself or either good enough light that feels meaningful.” And many people without even consciously realizing it slipped into a phase where they start to say, “I don’t matter’ or “My life doesn’t matter.” “What’s the point anyway, I wish I was dead.” “Nobody would be sad if I died.” And sometimes this goes into a place where they start to think that, you know, “I think I’m a burden, I think I am not of value, and what does it matter if I die? Nobody will miss me.”
First things first, I always say that one should not fear asking these kinds of questions if it’s [to] a family or a member or a loved one because it’s a very common thing we see in people with depression, even if they’re not at a point where they’re going to do anything about it. This kind of negative thought pattern is actually very core to just the symptoms of depression themselves, and many of the people who are […] stuck in this thought pattern find that when the depression lifts, these thoughts also get better and go away.
So I think you want to first start by thinking of it as a part and parcel of depression, and not be fearful of asking or checking in [with loved ones] about these thoughts if a person does have them to see hey if you have them because it might be a great sense of relief for someone to share this with somebody and now somebody knows, which means somebody can help, which means somebody can point you in the right direction of what can happen next. And so that is the first thing, asking, checking in, and knowing about it is extremely important.
The other thing that is also important is there are studies out there that show that there may be a very, very small, but nonetheless, important thing where when you start treatment, whether with therapy or whether with medication, there can sometimes be a change or a worsening of these thoughts initially.
That does not mean that the treatment is not working.Dr. Vidhya Krishnan
Sometimes what ends up happening is treatment makes a person be able to see where their life is a little bit more clearly, and what they see around them may not be something they like because of how much damage depression has done to their life and their circumstances and it can be very disheartening, to begin with. That’s exactly the point where we need to let somebody know that help is on the way, that there is light at the end of the tunnel and holding their hand.
So, instilling a sense of hope and knowing that they have people who are in their corner, people who are rooting for them (who know what they’re doing and who are able to help can preserve that sense of fullness), almost a “substituted hopefulness,” which comes from the outside until the actual treatments for the depression are able to kick in. So there is a period of vulnerability where we might know about these thoughts and feelings but we are not quite in a place where we are able to fully address them, which is when the external help a friend, a colleague or parent or relative, a doctor or a therapist can be so important and so valuable in supporting someone through that particular phase. But most times, as the depression improves, simultaneous to that we also see an improvement in these thoughts and feelings, automatically.
But if that’s not the case, and you’re not seeing those changes, therapy can play a significant role. Because sometimes these suicidal thoughts are almost a, I wouldn’t say a maladaptive coping, it’s felt like “That is the solution to my problems.” And so finding alternative solutions in conjunction with a really good therapist can replace these thoughts and feelings with other, more helpful thoughts and actually have a good chance of being able to help these thoughts and feelings.
So I think you want to think of suicidal thoughts and tendencies almost lockstep with the depression in your treatment of depression, as one of many things we try to address the same way we might try to address sleep or difficulties or appetite difficulties, and this is just one more of those things that we deal with.
TF: Yeah, that’s super helpful to know. I think it’s really nice to know that it’s not something that’s uncommon for people with depression, and it’s, you know, something that happens and it’s something that can be treated and something that can be improved with medication and with therapy. So that is an amazing thing. And thank you so much for joining us today in this interview. I learned a wealth of information, and I’m sure a lot of our listeners did too. So thank you so much.