Introduction & Round 1: Do major depressive disorder (MDD) symptoms indicate treatment for both the body and mind?

Meet the knowledgeable participants for this debate on MDD treatment approaches. Tina Matthews-Hayes argues for treating MDD as a mental health disorder, while Desiree Matthews provides support for a holistic treatment approach. Then, in the first round of this debate, our leaders address whether MDD symptoms indicate treatment for both the body and mind.

Transcript:

Brooke Kempf, MSN, PMHNP-BC: Hi, I'm Brooke Kempf. Welcome to Great Debates in Psychiatry, which is brought to you by Psych Congress Network. In this debate, we're going to discuss whether MDD should be managed as a mental health disorder or approached holistically. Now, before we start, I'm going to have you take a quick poll. We would like you to respond to this poll that you're going to see here on your screen, so please go ahead and respond to those questions now.

Brooke Kempf, MSN, PMHNP-BC: Excellent. Now, I have the honor to introduce you to our two participants today. Joining us today are Desiree Matthews and Tina Matthews-Hayes. So, we have two Matthews’ here. No relation, right? Yeah. Okay. Now, it's kind of a mouthful. We're going to be talking a lot today. Is it all right if I call you by your first names? (Yes. Please.) Okay, perfect. Okay, so Tina, you're going to be supporting the side of treating as a mental health disorder, and then Desiree, you're going to argue for the holistic approach, correct? (That is correct.) Okay. Well, I am so looking forward to this. I know this is kind of a hot topic now. I'm sure you ladies will agree. I think that with the world of things like social media and individuals getting input from different resources, there's a lot out there regarding mental health treatments, whether medications are effective, talking about their side effect profiles. Then, a lot of individuals can get a lot of recommendations when it comes to treating holistically. So, I know depression is kind of multifactorial, so of course, treatment options could be multifactorial, but that is why I'm glad that we have our experts with us here today, and I cannot wait to hear from you. So, let's jump right into round one. Our first topic of debate, and what we're going to talk about is: Do MDD symptoms indicate treatment for both the body and the mind? Tina, we're going to start with you. Can you please go ahead with your opening argument?

Tina Matthews-Hayes, DNP, FNP, PMHNP: Absolutely. So, I think the first thing I would like to, you know, when I look back over, well, over a decade of experience working in psychiatry, the one thing I realized in psychiatry, and especially in depression, MDD, is there is no one size fits all ability to tackle every single patient. If you look at the statistics, about 80% of the patients coming in for treatment have been suffering in silence. So, they have had depressive symptoms, on average, between 5 and 7 years. So, when they're coming into us, they're already feeling pretty low; feeling, you know, feeling pretty rough. Unfortunately, when they come in, they're also usually seeking a, you know, a quick fix. A happy pill. I usually call it the Tylenol phenomenon. You know, if you get a headache, we give you Tylenol, and it goes away.

However, everyone in this room knows mental health is not like that. Right? You know. I try to explain initially up front that, you know, we're looking at the two different ways to treat that. You know, we're looking at depression. It's more of a marathon, not a sprint. And we almost have to look at it as more of a chronic disease state, say, like weight loss. It's an ongoing manner of treatment; not so much a very quick end to a treatment. That said, we cannot overlook the ripple effect of depression. So, it definitely has massive impacts to the lifestyle, but it's also impacted by the lifestyle. However, when that patient is walking in the door, I'm looking at their current lifestyle: their ability to hold a job, get along with their wife, get along with their family, get up off the couch, and even move.

So, considering all those things and the initial picture, then we also look at the stress factors, you know. Stress in work, stress at the current world climate, and even traumas. So again, my position is that, sometimes, if we avoid delaying the initiation of pharmacological treatment early on, that then can add to that continuum of time when they've already lost, sometimes, 5 to 7 years of not feeling well. I kind of want to get them moving quickly. Again, you know, marathon, not sprint. Right? But moving and having some resolution of symptoms as quickly as possible. But understanding, again, safety is always assessed. I think Desiree and I can probably put the blanket statement out there. Any patient, regardless of how, you know, when we're assessing them, initially, we assess for safety and the degree of depression. So, if a patient is clinically ill, we escalate that. But I think in our conversation today, we're assuming it’s, you know, a mild to moderate depression.

Brooke Kempf: We're off to a great start. Desiree, let's hear your opening argument.

Desiree Matthews, PMHNP-BC: Thank you, Brooke. Thank you, Tina. When it comes to approaching the treatment of major depressive disorder, or MDD, when I look at the evidence, and I look at my clinical practice, the treatment of MDD really necessitates a holistic treatment approach, and it may be optimal for many patients. My background is in community mental health, and I've treated countless patients living with MDD. And I really ran in, very quickly, into my practice of the problem of patients not responding and, or failing to achieve remission with first-, second-, third-, or even fourth-line medications. My patients were hopeless. They were not happy with having to try more pills. When I looked at their medication regimens, polypharmacy was really the commonplace rather than the exception. So, it became really obvious to me that there was a lot more that had to be done in that treatment session other than writing a prescription.

When you consider that depression is such a heterogeneous disease, you see a lot of evidence pointing towards the fact that there may be factors that play into, play a role in depression, like changes that can occur due to poor diet and sedentary lifestyle. Things like inflammation, oxidative stress, or free radical formation, HPA-axis dysfunction, changes at our epigenetic or genetic level, changes in neurogenesis, alterations in gut microbiota, and mitochondrial function. Our diet and activity level has been shown to really improve or worsen metabolic contributors to mental illness, including depression. So, when I'm talking to my patients about their depression treatment, it's not just talking about medication. It's really talking about things that they can do in order to empower themselves to help manage and treat their depression, oftentimes along with medication. But again, it's that shared decision-making. Not all patients want medication. Not all patients are okay with therapy or diet and exercise alone. So, it's very careful assessment of both the evidence and what the patient is willing to accept. At the end of the day, we can prescribe medication, we can prescribe a treatment protocol, but if the patient is not on board with it and they're not willing to go forth, then it's a moot point.

Brooke Kempf: Those are all great points. Tina, I'm excited to hear about your rebuttal.

Tina-Matthews-Hayes: So again, I completely agree with everything that Desiree had just mentioned. The only area I would point out from my position of pharmacology is that we need to proceed with caution in our depressed patients, especially our obese depressed patients. Why is that? Because there is a well-documented resource on how health care providers view obese patients. And there's a health care bias when we're treating obese patients. So, when a patient comes into us and tells us that they have no motivation—they're tired, they have depression—the last thing they want to hear is, “That's because you're overweight. And what I need you to do is go on this diet and start exercising.”  But if I can't get them off the couch, to begin with, it becomes, again, the shared decision-making. The conversation of, okay, if I could start a medication to maybe alleviate some of that amotivation, some of that, like I said, inability to move themselves off the couch— lift that mood a little bit—then, sometimes, I can get them to buy into some of the other aspects of lifestyle changes.

Many obese patients currently feel shamed when they go in to see a provider. So, everything that they go into complain about is often blamed on, quote, ‘I'm told I'm fat.’ That's why I have depression. That's why I have strep throat. That's why I have ridiculous things. You know, I even disclosed from personal experience I once went in for decreased lack of energy, and I was, you know, 150 pounds I've lost; it was not good enough. My provider shamed me when they she saw my lab; she saw my iron levels were critically low. So again, that bias is definitely there. So again, proceeding with caution. I think is always a good idea. But we can't argue the facts. We can't argue the science; as Desiree pointed out, it's there. It's very clear. So, I think approaching our patients with a non-judgmental attitude coming in, being on their team, a team approach to how can we tackle this.

Here's our options here. Here's how we can work together. So, having a like a multifactorial and authentic approach to those patients is going to lead us to the best outcomes in those patients. Lee Carter recently published an essay. It was titled Fitness Means More Than Losing Weight, which, as providers, I think that is a great read. It's a quick read that gives us insight on how we can use exercise as a means of gaining strength and as a positive coping skill vs just doing the exercise to lose weight to, you know, to become less depressed. Right? More importantly, it gives insight for the providers into how that message is received to some of our patients. So, again—last but not least—I think the last thing I would comment is, you know, understanding and mastering motivational interviewing and how to talk to our patients, especially when they're obese. We know there's a correlation. We know that can help them. How we tell them to make those changes is everything.

Brooke Kempf: That is so true, Tina, and I love this. I'm hearing that team approach from both of you because we do, we really need to partner with our patients within this treatment. So, thank you, Tina, for that rebuttal. Desiree, please go ahead with your rebuttal.

Desiree Matthews: Thank you. So, to add to what Tina had mentioned, talking to your patients and developing rapport, helping them understand the rationale for the treatment plan that we developed together between patient and provider. If you look at one study conducted recently by the University of North Carolina, it found that only 12% of US adults are considered optimally healthy. This highlights the widespread issue that affects the population at large. So sometimes, discussing patients and statistics and health care outcomes can help patients not feel alone. We know that we need to really engage in a holistic approach for health care to not only address mental health but also the physical health. It's evident that majority of individuals in our society are grappling either with metabolic syndrome or at risk of developing it. And this really looks at the need of reevaluating our current treatment models and how do we talk to our patients about treatment in a non-judgmental way, as Tina had mentioned. We see that there is certainly a bi-directional relationship between obesity and depression, and this was highlighted in a meta-analysis published in JAMA Psychiatry, showing the compelling evidence in the need to approach mental health and physical health in tandem together. The study shows that obesity does increase the risk of developing depression by 55%. Simultaneously, individuals who experience depression also face a heightened risk of developing obesity. So, we see this interplay between these two conditions, really suggesting that an intervention that solely focuses on mental health or physical health, will really only address part of the problem.

Brooke Kempf: Thank you, Desiree. You ladies are making wonderful points. I feel like I should be taking notes here. Hopefully, the audience is. So, thank you, ladies, for all of that. But I'd love to hear your closing statements for this round of the debate. Tina?

Tina Matthews-Hayes: Again, I feel like I need to hold up a sign that says, ‘I agree, Desiree.’ Again, holistic, you know, it takes, again, a holistic approach, meeting a patient where they are. There's no magic bullet, and I wish there was. There is no quick fix, and I wish there was. However, you know, I think that sometimes if, you know, if we, if a patient comes into us and we acknowledge that they may have been waiting for quite some time to even get through our doors, and there may already be impacts to their life—to their marriage, to their ability to work—suggesting that exercise for another 6 months or maybe, you know; I know there's even some providers that will suggest therapy only for 6 to 8 months before they start medications. That delays the possible relief of some of those symptoms that make it so hard for the patients to be engaged—to get up off the couch, to care about what they're eating, to care about exercising. So, sometimes in those situations, starting medications a little bit earlier, but also having a good mastery of pharmacology and understanding what medications to start to help with motivation, you know, weight, all of those things are very important. But again, initiating medications earlier can help alleviate some of those symptoms, which can lead to better patient outcomes a little bit earlier on, rather than pushing off another 6 to 8 months when some patients have already lost 5 to 7 years.

Brooke Kempf: Great, excellent points. And Desiree, your closing statement?

Desiree Matthews: Thank you, Tina. I can definitely resonate and understand your side of the argument. Again, we have to take a look at the statistics and the evidence. Right? Really treating the body is treating the mind and vice versa. We know the alarming statistics regarding the health of Americans, not only physically but mentally, and that bidirectional relationship between obesity and depression really calls for a holistic approach. I would say maybe adding to that not only holistic but a truly integrative approach. Certainly, not all patients may be, you know, good candidates for holistic only treatment. And that's really where integration of both medication and other holistic and adjunctive treatments, such as exercise and diet changes, can really help provide more of a comprehensive and, hopefully, effective care to individuals facing these intertwined health and mental health and physical challenges. So, let us not view the body and the mind as separate entities rather than as interconnected aspects of our overall well-being, deserving of equal attention and consideration when it comes to treatment planning for patients living with MDD.

Brooke Kempf: Ding, ding, ding. That concludes round one of our great debate series. Thank you both for fantastic arguments. So, I'm curious to see what the audience feels. So please tell us who you think won this round by answering the poll questions you see here on your screen. And be sure and join us next time for round two, where we're going to be discussing how the treatment approach influences the speed of recovery.