online conference transcript

Dr. Louis Cady: on the latest advances in depression treatments, antidepressant medication, ECT (electroconvulsive therapy) and psychotherapy treatments for depression.

David: HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Depression Treatments". Our guest is psychiatrist, Louis Cady, M.D.

Dr. Louis Cady is a board-certified psychiatrist based in Evansville, Indiana. In addition to his private practice, Dr. Cady, has written two books, gives lectures, and is one of the few male psychotherapists who conducts a weekly support group for women on women's issues. You can visit Dr. Cady's site at http://www.drcady.com.

The reason Dr. Cady is here tonight is because one of his areas of expertise is Depression, especially treatment-resistant depression.

Good Evening Dr. Cady and welcome to HealthyPlace.com. We appreciate you being here tonight. Many people who visit our site have been living with depression for years and can't seem to "get over it". How difficult is depression to treat?

Dr. Cady: Good evening David and guests. It is a pleasure to be here.

Depression is both an easy and a difficult condition to treat. Let me explain in the next several sentences.

Depression, as we understand it, is a biological disturbance in the brain and not a defect in moral character, moral laxity, etc. Treatments for depression which are currently available these days, are generally safe and effective. This wasn't always the case.

If depression is treated skillfully and carefully by an expert, it's usually not that difficult to bring it to heel. If it's been a problem for a long period of time, or if it's severe, it can be more of a problem, require quite a lot of time to get the medicine right, and, of course, we can't forget the aspect of psychotherapy or talk therapy to help people deal with the psychological realities of it as well.

I know, a long answer to what looks like a simple question, but hopefully this will frame our discussion for this evening.

David: Why is it that some people can recover from their depression in a shorter period of time than others?

Dr. Cady: Several explanations. Some people's depression isn't as bad as other's, and some people respond better and more briskly to antidepressant medications. And some people have a moment of startling, clear insight in their psychotherapy which affords them a glimpse into a different, better way of making decisions and conceptualizing the existential (and other!) aspects of their existence. Particularly in relationships which are not good, business situations which are not going well, and when they have a warped and distorted view of the world. Also, the newer antidepressants simply work faster than the old-timey way of treating depression with tricyclic antidepressants.

David: A few minutes ago, you mentioned about being treated by an expert who is skillful. Can you clarify what that means and how an individual would find that type of person to treat them?

Dr. Cady: Certainly. I see two primary psychopharmacological ("pill prescribing") misadventures in physicians from whom I get patients who are not doing well:

• underdosing
• overdosing

In underdosing, the medication is never pushed up high enough to get the job done. In overdosing, the medication is typically started so high, or "too hot" - to use the Goldilocks analogy - that the unfortunate patient gets so many side-effects from the first dose... or first few doses... that they are already off to a bad start.

Finally, antidepressant medications should be selected carefully for the type of depression which one is treating. Every medication on the US market right now could be thought of in a particular "niche" for a particular type of depression, or, conversely, in particular "niches" where their prescribing could be harmful. Therefore, "choosing wisely" in terms of selecting the right agent, and then prescribing with a suitable level of sophistication and technical finesse - in other words, not turning your patient into a zombie or putting them up on the ceiling with anxiety from the first dose of medication they pop into their mouths... these are the criterion I would look at for "skillful".

David: Are there tests that can be given to determine what is wrong, brain chemical wise" and which medication should be used?

Dr. Cady: Excellent question. At one time, is was thought that the "Dexamethasone suppression test" could tease apart "real", "biological" or "melancholic" depression for the more reactive, "psychological" types. Not true. There is currently no available blood test in clinical practice which can determine which antidepressant to select. On the other hand, the astute clinician can, if listening to the patient clearly and empathically, come up with some reasonable hypotheses about what neurotransmitters might be out of whack. One classic example would be a woman suffering from premenstrual dysphoric disorder, with carbohydrate cravings, "low mood" on a monthly basis, and classic signs and symptoms of depression. That is a serotonin deficiency unless proven otherwise. Accordingly, a medication which boosts serotonin (SSRIs) should be selected. That would not include such things as Wellbutrin - a great medication, to be sure, but not one specifically indicated for this condition. That is an example of how I would BEGIN to conceptualize which medication to select.