Decoding Depression: Is Your Brain Lying to You?

WEBVTT
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You're not depressed.
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Just unfinished.
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This is a podcast for leaders, high achievers, and entrepreneurs who have built impressive lives on the outside, and yet sense something is dying on the inside.
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If you ever stared at everything you have accomplished and felt strangely empty, this show is for you.
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Today we're talking about depression, and we're going to bring facts, we bring context, and we bring hope and possibilities for you.
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Depression doesn't need any introduction.
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We talk about it whether in cocktail party, in clinical environment, in social media, and it's a very human experience.
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What is not there is trusted data, trusted insight about what is depression?
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What does it mean if I'm depressed or somebody in my family, a coworker, and what are the options and what are the possibilities for healing?
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I'm very excited to have with us an expert, Dr.
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Diane McIntosh.
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She's a psychiatrist based in Vancouver, and she's an author of a wonderful book, which I found several years ago, This is Depression.
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It is so wonderful as science.
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She talks about medication, about what depression is, how do you diagnose it?
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So we're gonna get deep and we're gonna geek in out today about what is the science of a depression.
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Before we go further, about disclaimer, this podcast is for educational and informational purposes only.
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If it's not medical or mental health advice, we are not providing therapy and should not replace care from a qualified professional.
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If you have any questions, concerns about your health or well-being, please speak with your doctor or mental health provider.
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Let me describe about Dr.
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McIntosh.
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She is from Vancouver, Canada, and she's a psychiatrist and clinical assistant professor at the University of British Columbia with over two decades in community psychiatric practice.
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She has a pharmacy degree.
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She's a pharmacist, which is very interesting, and completed her medical school in a pediatric residency and then became a psychiatrist.
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She is a founder of a CEO of Rapid Health, Chief Neuroscience Officer of TELUS, and a co-founder of SwitchRx and founder of me.
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She has her own podcast and writes about burnout, sleep, loneliness, trauma, and depression.
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Dr.
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Macintosh, welcome.
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So great to see you.
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Oh well.
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Thank you for inviting me.
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Question for you.
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You said when you're depressed, your brain lies to you.
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That statement, what does it mean?
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And I know you know this well, but when you're experiencing a really a serious depression, your thoughts and your feelings are mostly very negative.
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You think you're worthless and useless and hopeless.
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Everything wrong in your life is your fault.
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And sometimes depression, particularly a first depression that you've had in your life or the first couple of depressions, there is some kind of stressor.
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And it's you may be feeling very guilty or frustrated about something that you've done.
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You you feel regret, but depression amplifies those feelings and makes you feel like there's no path ahead.
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Your brain is driving those thoughts.
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So that's why I say your brain is lying to you because there's always a path ahead.
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So those feelings of hopelessness, worthlessness, uselessness, they're amplified by your brain telling you those lies.
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And it's why what you do and the power of social support is so important because it can help to push back on those negative thoughts that you have.
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If you're always hearing this in your head, you're always thinking this way without people around you giving you other context, it can become very isolating.
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Sometimes you need more than social support and talk therapy, and medications can be a very appropriate treatment and help with those kinds of thoughts as well.
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I remember from personal experience over the years.
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I come from a family, a background that I didn't know this for a long time.
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My mom was clinically depressed, my dad was depressed, grandparents, so on.
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So I grew up to your point.
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I felt that I was smiling, running marathons, very successful, but deep down I felt broken.
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I feel something missing.
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I feel that there's a darkness in my soul.
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I cannot talk about it.
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I know it's there.
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Nobody cared, I felt, to listen to me.
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Where do those sense of broken?
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There's things missing.
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I'm not well.
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Where do they come from?
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Well, your brain creates all of your thoughts and feelings, but your brain creates those thoughts and feelings from your experiences.
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So we have all of us are made from the our parents, right?
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50% of our DNA comes from our mother and 50% from our father.
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And that creates our temperament, which is kind of hardwired.
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You know, you may have been a very easy baby, quick to warm up, or you may be a little bit more standoffish kind of person.
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Your temperament, that's hardwired.
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But then your personality is built on that foundation of your temperament, on your genetic makeup, but it's also heavily influenced by our experiences, by our environment.
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So you probably had your experience coming from, or sorry, both the genetic load that came from your family.
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If you had both mom and dad and extended family having individuals who had a lot of depression and anxiety, maybe other disorders.
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And on top of that, the experience of living with people who were chronically depressed and other aspects that can be experienced, particularly early life difficulties that can have an impact on your risk of depression and anxiety later in life.
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That's right.
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And that became a lifestyle for me.
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And you know, like in fact, what is interesting, I became very successful in the business world.
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So I the people with, in fact, there's a term Ardashir Mehran, PhD L O P, life of the party.
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People would say, Arashir, you're always so positive, you're energetic.
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If there's a gathering, I was the first person to invite.
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And I would tell people, I don't feel well, I'm depressed.
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And they would say, No, I just had a bad day, take vacation, you have a drink.
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And I felt there's an experience of not feeling well, and was my story over the years playing.
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Part of the healing, I didn't know how to rewind, unwind that story became part of my upbringing.
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Well, I think sometimes people who have really chronic negative feelings like that, emptiness or pain, that they become very good at covering it up.
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They develop a social face, but the pain of that can continue to grow.
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And you obviously found some important outlets for that.
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Being able to help other people is probably one of those paths to finding recovery, feeling better, managing your depression.
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Sometimes people don't find those paths, and that pain just stays in them and starts to come out in other ways.
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So, what you describe is extremely common.
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And men in particular, I will say, tend to hide, push those feelings down a little bit, not as open with those feelings.
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And I think we're talking a lot more about depression and anxiety and all mental illnesses, men are talking more, and I think that's really important.
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Actually, to stay with this one that so I have brothers that the when we talk about family, mom and dad depression, my brother says, I don't want to talk about it.
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I don't want to talk about it.
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And I find that in the my colleagues, men defended discussion about feelings, heart feelings, depression, uncomfortable, not relevant, or just I don't want to go there.
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I find women can go there quickly, can name it, and actually they want to talk about it.
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How do you see it in your practice?
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You know, gender differences.
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I think that's generally true.
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And boys were raised, I think, generally, to not be too emotional.
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Don't be a crybaby, you know, what are you, some kind of girl because you're crying, right?
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But that's changed.
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I think we've raised our boys, we're raising our boys to be a little bit different now, to be able to be more in tune with their feelings, to express them.
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It's appropriate to have emotions and it's appropriate to have a range of emotions and to share them with the right people at the right time.
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And I don't mean that we all should be walking around in a puddle of tears all the time because that's going to make it difficult for you to create friendships and remain employed, but to be able to show emotions at, first of all, before you even show them, recognize that you have feelings that are hurtful or painful or difficult.
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Those are sometimes called cognitive distortions.
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And it's one of the real values of seeing a great therapist, someone who really knows their stuff, is being able to help identify those thoughts that you have that you don't even realize are the way that you're thinking about yourself all the time.
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And they're distorted.
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And people often don't recognize that they're thinking all the time, I'm stupid.
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That was stupid.
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You're an idiot.
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Why did you do that?
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All over and over again.
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They're self-talk being very negative.
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So having a great therapist can help you to find those thoughts.
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But if you're talking to your brother and they're not into it and they don't want to talk about it, you can't force them to be okay with that.
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So you have to surround yourself, find people who are okay with that.
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And that's the beauty of finding a great therapist.
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That's true.
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You mentioned three times finding a great therapist.
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How do you find a great therapist?
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Because I've gone over seven therapists over the years with my depression, wonderful people.
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I feel they missed me.
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Quick diagnosis.
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How do you find a great therapist?
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And how do you define a great therapist?
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That is a really good question.
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And there is a reason why I say that.
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And that's because I believe that talk therapy, you know, I'm a pharmacist, and then I went to medical school and became an adult psychiatrist.
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And my job, my particular area of expertise is in prescribing medications for people who have severe mental illness.
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That is my skill in helping people who have a really severe illness.
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But I also know that talk therapy is a really powerful treatment.
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It has an impact on gene products, the kind of proteins we make.
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It impacts how your brain works.
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So you can do a whole lot of damage if you're not a good therapist.
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So the reason I say really good psychotherapy, really good therapist, is because of the fact that person holds a lot of power in your life by having more information about you than you have about them.
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They are asking you questions and helping you to think about things in a particular way that you want to make sure is driving you in the right direction.
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And I've seen myself, I worked in PTSD for a long while, that people who have had trauma in their background have had someone who probably well-meaning opened a can of worms from their past that they felt that they had had well managed and they weren't able to put the toothpaste back in the tube.
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They weren't able to put those worms back in the can.
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And in fact, it caused a huge amount of problem down the road because that person wasn't skilled enough to know that is a well-contained memory and trauma that is managed.
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But opening a whole bunch of stuff up without knowing how to put it away, that's dangerous.
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So, how do you find a good therapist?
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Well, first of all, the the most training that you can have that you can find.
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So making sure that you have someone who obviously you have to be able to afford that individual, but they have good training, they have really good reviews, they're associated with licensing bodies that are respected in your community.
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If you have a friend who's seen someone who's a said, this person really helped me, that's really meaningful.
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But you have to have a connection with the person you're working with.
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That's right.
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So I tell patients, my patients, if they're going to see someone, give it a couple of sessions.
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But if you don't feel like you connect with that person, that's okay.
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That therapist should know too, that's not a good fit.
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Go and find someone else.
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Don't stay with someone simply because you feel bad.
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You want to find someone that you can make a connection with, you feel safe, trust, and respect their skills.
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That's right.
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This is so helpful.
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And being a student of psychotherapy, and uh, I was trained initially as a psychoanalyst in CBT and later on developed deep expertise in somatic therapy with Dr.
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Peter Levine and so on.
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And I found that as I got better in terms of my own healing, you know, like understanding human behavior, the quality of my work also changed.
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That as I became more humble, became more attuned, calmer, that Dr.
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Meron knows everything versus no, Dr.
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Merron has his own struggles, but at this point is helpful to you.
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I found that therapists and clients enjoy our conversation more, we connect more, and their results are faster.
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And I told people, I don't believe in open-ended therapy.
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I don't open the long-term therapy.
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If therapy with the right therapy is done right, outcome focus, managing symptoms, you can get results in matter of weeks and months versus years and years and years.
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I think something that's important that you said is that we do get better with time too.
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Like therapists, and it doesn't mean that you can't have a young therapist who's excellent, but you do gain skills over time of working with many patients and recognizing what does work, what has been helpful, and being open-minded in all of your relationships with your patients so that you recognize, and I certainly learned this very early on, I learned more from them, I think, than they learned from me.
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So being attuned to how what I say is received, how they experience it.
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Do they come back and reflect on it with me in a way that I didn't intend it to be shared?
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You have to listen carefully.
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And sometimes it takes time.
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You got to grow up a little bit as a new therapist and learn.
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And also put putting your own experiences into the way you approach patients.
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One thing I wanted to get back to, though, that you said was really that I thought was really important.
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You said I saw a number of therapists and they they missed my diagnosis or they they weren't helpful.
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And I think this is a huge problem in psychology and in psychiatry.
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We miss diagnoses too much.
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And in fact, if you think about bipolar disorder, it's missed about 90% of the time.
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And on average, it takes 90, 9.
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90, 90, 9, 0.
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It takes 10 years and four different doctors before you get the right diagnosis.
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And this has become really one of those, you know, my purposes in life as I as I try to educate to say we need to do a better job of getting the right diagnosis.
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And unfortunately, in psychiatry, we're one of those medical specialties that has no objective tests.
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There's no blood work, a brain scan that I can go, ah, you got this, and therefore this is the right treatment, like you would have in oncology or cardiology.
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So we do have, however, clinical scales.
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And so using those scales, the assessments that patients complete or that we complete, and really try to make sure that we stick to the science.
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And that's I wanted to also get back very quickly because the way you started this with about my book, which I I really appreciate.
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It's very kind of you.
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There's a lot of science in there, but we have a problem in the world right now about how people view science because of what we all went through with COVID.
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This belief that we can't trust doctors and you know, science is hoo-e.
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And in fact, science at its core is never settled, it changes.
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We learn constantly.
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And what happened during the COVID pandemic was we had this coronavirus, and coronaviruses usually do this.
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So everyone said, Well, we think it's a coronavirus and it usually does this.
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So let's do that to try to manage it.
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And then we learned this was a different coronavirus.
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Gumping back to my book, there's a lot of science in there, but it needs to be updated because our understanding of the brain has changed even in the last since 2018, in the last eight, nine years.
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Now we understand new ways of approaching the brain and we understand differences in brain structure that all and it's about to explode with AI and quantum computing.
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That's right.
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So science constantly changes.
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So we have to hold on in the midst of trying to treat patients with the science we know now, recognizing our understanding will likely change.
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That's right.
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So, Diane, as you're talking about the quality of the patient can be misdiagnosed and not really understood.
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How does it work like when a patient comes to you?
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What is your approach to arriving at the proper diagnosis?
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I do agree that experience is really important.
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So now I know uh so much more about a usual presentation of depression.
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And we tend to think about depression as it's this blue book of psychiatric diagnosis, the DSM.
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And we say, yeah, this is depression.
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That that is not necessarily depression for everyone, but it the reason we have that big book is so that when we do research, everyone that's in a study looks just about the same.
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Because if we have, you know, depression defined 80 different ways in a study, it's not very helpful in being able to draw conclusions from the research that we do.
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But if I have a patient who's sitting in front of me saying, I'm depressed, I'm sad, first of all, I do all of my clinical scales, and that helps me to know where are they on the depression scale, where are they on the anxiety scale, what is their risk of bipolar disorder, how are they sleeping, how are they functioning?
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So I have all of those scales done that help to drive my decisions.
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And then I dig in on what did what does depression mean for you when you say you feel this way?
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When you say you feel anxious, and actually I saw someone yesterday, I've seen her a long while, and she's never had an explanation of anxiety that would fit anyone's anxiety description, but she absolutely has an anxiety disorder.
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And so it means that different people present in very different ways.
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So after I've done all my clinical scales and asked them questions, my most important thing is listen, what are they telling me?
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What is their experience?
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No, no diagnosis exists without the symptoms, but also without functional impairment.
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You can't do your usual roles, whether at home, at work, at school, in social life, and also that you're distressed.
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It's impacting your life because you feel distressed.
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This is so helpful.
00:20:25.039 --> 00:20:35.440
I mean, the flashback, you know, like when I was going for my own therapy, partly was they were two quicks saying depression, but then it says, So what do I do with it?
00:20:35.599 --> 00:20:38.559
You know, like, you know, to your point, there was no explanation.
00:20:38.799 --> 00:20:40.960
So how did you become depressed?
00:20:41.119 --> 00:20:42.160
What was going on at home?
00:20:42.400 --> 00:20:44.079
Your mom, you what did you learn?
00:20:44.400 --> 00:20:51.119
What they missed that I was in a state of anxiety freeze, coming from you know, sense of family trauma.
00:20:51.519 --> 00:21:03.599
But they also totally missed that I had elements of ADHD, impulsivity, lack of attention, again in the family dysregulation or like uh instability.
00:21:03.839 --> 00:21:14.799
So their feedback was go get a leadership coach about project management, uh, managing your work versus understanding that uh instability is inside.
00:21:14.880 --> 00:21:17.440
How do I manage my anxiety and settle?
00:21:18.480 --> 00:21:26.880
It took me to figure out what was going on with me and also kind of like self-healing with the help of my wife.
00:21:28.799 --> 00:21:34.720
This could have been prevented almost 15 years, 20 years ago for me not lingering.
00:21:35.200 --> 00:21:44.079
So I really appreciate you mentioning proper diagnosis can save, can bring hope, can bring results.
00:21:44.880 --> 00:21:51.599
And you have to think about the most common reasons that people are struggling and screen for those, right?
00:21:51.759 --> 00:21:54.400
So I said depression, anxiety, insomnia.
00:21:54.559 --> 00:21:56.240
I also do an ADHD screener.
00:21:56.480 --> 00:22:06.240
Yeah, and it's another one of those places where we have so So much science supporting the diagnosis of adult ADHD, mountains of science.
00:22:06.480 --> 00:22:19.680
But because some people think, you know, well, it's the pharma companies trying to make money, they negate years and years and years of really good scientific research just because they have a bad feeling about pharma.
00:22:19.759 --> 00:22:23.920
And there's no doubt that the pharma industry has behaved badly in the past.
00:22:24.079 --> 00:22:26.799
In Canada, there has been a huge amount of regulation.
00:22:26.960 --> 00:22:28.480
There's no giving anything.
00:22:28.640 --> 00:22:33.119
You go to a meeting, there's not a pen that it has a pharma name on it.
00:22:33.519 --> 00:22:34.559
This has changed.
00:22:34.720 --> 00:22:46.720
But I can tell you, if you or someone you love, somebody you really care about, your child has a serious mental illness, you want the best treatment possible and you want the most innovative treatment.
00:22:46.880 --> 00:22:48.880
No drug will work if it's not taken.
00:22:49.039 --> 00:22:58.960
And most of the problems we've had with the way people view antidepressants negatively, they're addictive, they they make me feel like a zombie, is because they were terrible drugs.
00:22:59.200 --> 00:23:00.480
We have new drugs now.
00:23:00.640 --> 00:23:10.960
But if we don't have a pharma industry that is innovating, we will not have better drugs that people are willing to take that make a huge difference in the quality of their life.
00:23:11.279 --> 00:23:11.759
That's right.
00:23:11.920 --> 00:23:19.359
So what you're talking about, that there are better drugs, and drugs need to be used and prescribed effectively.
00:23:19.519 --> 00:23:32.240
So case in point, uh last month I went for my annual visits in the and doctor the start to, I know the doctor, wonderful doctor, primary care.
00:23:32.480 --> 00:23:38.000
Start to read the list of questions, you know, PHQ nine, artistship, sleeping, energy, all of that.
00:23:38.160 --> 00:23:45.359
And uh for the listeners, pH 9, if you go do a Google search, patient health questionnaire, nine questions.
00:23:46.480 --> 00:23:50.480
It's the first line of defense for depression, you know, like you're just getting sense.
00:23:50.559 --> 00:23:53.440
So doctor just asked those questions, Ardishire.
00:23:53.519 --> 00:23:55.039
I see you being depressed.
00:23:55.680 --> 00:23:57.839
Would you like me to prescribe medication for you?
00:23:59.839 --> 00:24:04.480
To your point being curious, the doctor, there's a lot going on in my the life, you know.
00:24:04.640 --> 00:24:08.720
Then I know I'm not sleeping, you know, the concentration, all of that.
00:24:08.799 --> 00:24:11.200
It's my depression is managed.
00:24:11.279 --> 00:24:16.640
I it's I don't need medication, it's I just need understanding better lifestyle management.
00:24:17.759 --> 00:24:30.640
If sheer fact right away was called pill for an ill, right away you diagnose me being high depression, and here's a pill that this requires an explanation, a conversation.
00:24:30.799 --> 00:24:39.119
In 20 minutes, visit the she was trying to be helpful, but that's how you create the bad impression about medication.
00:24:39.440 --> 00:24:40.559
Does that make sense?
00:24:40.799 --> 00:24:41.680
Oh, absolutely.
00:24:41.839 --> 00:24:47.039
So there's two really important sort of motherhood and apple pie statements I want to make here.
00:24:47.279 --> 00:24:58.319
A clinical scale is not a diagnosis, it gives you information to say it looks like you have depression based on this scale that maybe is moderate, moderately severe, severe.
00:24:58.480 --> 00:25:06.640
So we know that if that is the case, sometimes people really benefit from medication at that level of depression.
00:25:06.720 --> 00:25:08.319
But that's not the diagnosis.
00:25:08.559 --> 00:25:12.559
I have to understand how those symptoms are affecting your life.
00:25:12.799 --> 00:25:23.599
So if you said to me, you know what, I always have felt like this and I feel like that's well managed, but I'm having a challenge over here or I need this, that's where we should focus.
00:25:23.759 --> 00:25:34.559
So the other motherhood and apple pie thing here is or statement is the patient, the client, the human being in the sense is the center of every decision.
00:25:34.880 --> 00:25:38.240
My job as a psychiatrist is to be a navigator.
00:25:38.400 --> 00:25:39.680
I have a lot of education.
00:25:39.839 --> 00:25:42.559
I was in university forever training.
00:25:42.880 --> 00:25:47.200
I know how to navigate mental illness, but you are the captain of your ship.
00:25:47.279 --> 00:25:50.640
And so I'm going to give you all the information I possibly can.
00:25:50.720 --> 00:26:02.880
And if I think that your illness is really very severe and I'm worried about your ability to care for yourself or others, I'm going to be perhaps more persistent than I would be otherwise.
00:26:03.119 --> 00:26:06.480
But ultimately, I want you to make every decision.
00:26:06.640 --> 00:26:10.000
I'm here as your guide, I'm your navigator, you're the captain of your ship.
00:26:10.160 --> 00:26:10.480
That's right.
00:26:10.559 --> 00:26:14.880
This is so helpful, Doug is a conversation about what is going on in your life.
00:26:15.200 --> 00:26:19.599
Dan, so part of that, the whole continuum.
00:26:19.680 --> 00:26:23.279
I mean, when I think about depression, is not binary, you have it, you don't have it.
00:26:23.359 --> 00:26:24.720
Like there's sadness.
00:26:25.200 --> 00:26:27.200
Then there is feeling depressed.
00:26:27.279 --> 00:26:30.720
You know, like even there's a I listen to Bruce Springs' songs.
00:26:30.799 --> 00:26:37.440
I mean, half the time he's reading about some sort of blues coming from a background and so on.
00:26:37.599 --> 00:26:38.720
It's not clinical depression.
00:26:38.799 --> 00:26:40.720
He writes beautiful songs about it.
00:26:40.960 --> 00:26:46.480
So, when is it life situations and when is it clinical?
00:26:46.880 --> 00:26:48.319
How do you see that?
00:26:48.640 --> 00:26:50.559
It's normal to feel sadness sometimes.
00:26:50.720 --> 00:26:58.480
And I would argue that you can't actually fully appreciate joy without understanding what sadness and pain feel like.
00:26:58.640 --> 00:27:05.279
You actually can't be empathic if you don't understand what it's like to experience sadness or grief.
00:27:05.440 --> 00:27:07.279
So sadness is normal.
00:27:07.519 --> 00:27:20.559
But and we all have times when we can feel depressed because we have some stressors, whether home or work or you know, with a friendship, feeling down for a few days, that's not depression.
00:27:20.880 --> 00:27:29.279
When depression becomes what some people call clinical depression or a major depressive episode, is when it persists for weeks.
00:27:29.599 --> 00:27:36.799
You have a really significant impact on your ability to function in your usual roles, causes a huge amount of distress.
00:27:36.960 --> 00:27:38.799
It comes with all kinds of symptoms.
00:27:38.960 --> 00:27:50.640
You can't sleep or you're sleeping all the time, you've lost your appetite entirely, or you can't stop eating, you feel hopeless and worthless, could be agitated, heavy, weighed down, slowed down, fatigued.
00:27:50.799 --> 00:27:59.200
All of this constellation of symptoms, along with functional impairment, along with distress, that is what is considered a clinical depression.
00:27:59.359 --> 00:28:03.920
And then beyond that, we often miss that there are comorbid conditions.
00:28:04.079 --> 00:28:24.400
There's anxiety that comes along with that, that we we should need to qualify because anxiety is harder to treat, takes longer if it's severe, usually higher doses of medication to manage, and also increases suicide risk, just makes everything worse when you have anxiety.
00:28:24.480 --> 00:28:25.920
Then there are anxiety disorders.
00:28:26.000 --> 00:28:27.359
There's ADHD.
00:28:27.599 --> 00:28:32.400
All of these have to be considered when you're working with someone who has a mental illness.
00:28:32.480 --> 00:28:35.599
So you don't just present with depression and okay, you're depressed, that's it.
00:28:35.759 --> 00:28:39.279
You have to make sure you've thought about all of the symptoms they're experiencing.
00:28:39.519 --> 00:28:39.920
That's right.
00:28:40.079 --> 00:28:52.400
And in that my case, you know, depression more or less was understood, but my anxiety and ADHD was not well understood and brought to my awareness.
00:28:52.640 --> 00:29:03.839
So now years later, I'm a therapist, and recently I had the client came to me and she said that I've been going a number of therapists, I'm going nowhere, and I just want it, I want healing.
00:29:04.240 --> 00:29:09.279
She was on three medications: one for depression, one for anxiety, one for ADHD.
00:29:09.680 --> 00:29:18.480
And she would talk about the all sorts of, you know, the feeling anxious, nauseous, diarrhea because of side effects.
00:29:19.440 --> 00:29:26.240
How would you work or support the individual who is on multiple medications?
00:29:27.759 --> 00:29:35.359
Sometimes multiple medications are necessary, and uh, but the approach that I always take is based on its severity.
00:29:35.440 --> 00:29:54.240
So if I have someone who has very significant ADHD, but also a really severe depression, or they have bipolar disorder and they have significant anxiety, I'm going to deal with their mood symptoms first, manage those with them, find the right treatment, and then treat the ADHD.
00:29:54.400 --> 00:30:08.480
But if I had someone who had significant ADHD, but their depression and anxiety actually could have been provoked, and it's not really, really severe so that it's impairing them, but it could be provoked by their ADHD.
00:30:08.640 --> 00:30:13.279
I may choose to go at the ADHD first because that may be all that's required.
00:30:13.440 --> 00:30:23.039
But most often I see people who have bipolar disorder, a very severe depression, significant anxiety disorders, they may have panic or OCD, for instance.
00:30:23.200 --> 00:30:28.720
So they I need to manage those first, and then I go after the ADHD.
00:30:28.799 --> 00:30:37.440
It's not that the ADHD isn't important, it is, but if you're changing two or three things at once or adding two drugs at the same time, it is confusing.
00:30:37.599 --> 00:30:38.640
That's one piece of it.
00:30:38.799 --> 00:30:40.640
So I do it stepwise.
00:30:40.960 --> 00:30:46.240
Also, one of the greatest challenges we have is access to tolerable treatments.
00:30:46.480 --> 00:30:51.359
So my purpose in life is to give my patient a medication.
00:30:51.680 --> 00:30:53.759
Let's use antidepressants as an example.
00:30:53.920 --> 00:30:57.279
We have antidepressants that people believe are addictive.
00:30:57.599 --> 00:30:59.599
No antidepressant is addictive.
00:30:59.839 --> 00:31:04.640
If they were, that would make my life easier because I can't keep people get people that could keep taking them.
00:31:04.720 --> 00:31:06.559
They stop them before I ask them to.
00:31:06.799 --> 00:31:11.519
But some of the older antidepressants caused what were called discontinuation reactions.
00:31:11.680 --> 00:31:14.480
Paxel was really terrible for that.
00:31:14.799 --> 00:31:22.480
No, I have not prescribed those in forever, like decades, because of the fact that they cause those kind of side effects.
00:31:22.640 --> 00:31:26.640
Antidepressants can make you feel flat or apathetic or zombified.
00:31:26.799 --> 00:31:28.799
That's a side effect of SSRIs.
00:31:29.119 --> 00:31:32.720
We can use other antidepressants that don't have that side effect.
00:31:32.880 --> 00:31:36.000
Some of them cause weight gain, some of them cause sexual dysfunction.
00:31:36.160 --> 00:31:39.359
I don't want to tell a 20-year-old, yeah, you're never having an orgasm again.
00:31:39.519 --> 00:31:42.079
Sorry for it for that, but you need this antidepressant.
00:31:42.240 --> 00:31:52.799
I want to find an antidepressant that allows them to have normal sexual functioning, not gain a ton of weight, and get their functioning back, get not be symptomatic.
00:31:52.960 --> 00:31:58.000
So, first and foremost, treat the most severe disorder with the best possible treatment.
00:31:58.160 --> 00:32:05.039
If one doesn't work, you have to try another because we don't have a lot of science to support no blood work or brain scans that tell me this is the right drug.
00:32:05.200 --> 00:32:06.720
So we do have to do trial and error.
00:32:06.960 --> 00:32:10.799
Soon as I've got that done, you gotta make sure that anxiety is managed too.
00:32:10.960 --> 00:32:12.799
Then I go after the ADHD.
00:32:13.119 --> 00:32:14.000
This is so helpful.
00:32:14.160 --> 00:32:19.359
You mentioned that when there are multiple conditions, you don't treat them all as equal.
00:32:19.519 --> 00:32:25.119
You look to see which one may be creating more disruption or has more need.
00:32:25.279 --> 00:32:34.160
You try to focus on that one, bring that to some level of balance, then work on the other one versus three drugs all at the same time.
00:32:34.480 --> 00:32:36.400
So there's a story of the person.
00:32:36.960 --> 00:32:45.440
There's a there's really an important factor here, and that is an imagine an ADHD and bipolar are our two most heritable psychiatric disorders.
00:32:45.599 --> 00:32:48.960
They run together far more than you would expect in the general public.
00:32:49.119 --> 00:32:53.359
So lots and lots of people who have bipolar disorder also have ADHD.
00:32:53.519 --> 00:32:53.839
Yeah.
00:32:54.240 --> 00:33:06.000
Many therapists or uh psychiatrists, family doctors, whatever treaters out there, prescribers, don't think that you can treat ADHD if you have bipolar, because ADHD treatments can activate bipolar symptoms.
00:33:06.160 --> 00:33:07.599
That's not the case.
00:33:07.839 --> 00:33:15.359
If you treat the bipolar first, really well manage mood stability, then you have to treat the ADHD.
00:33:15.519 --> 00:33:25.279
So what we do, what I do, treat the bipolar, get that person as stable as possible, and then very, very slowly manage their ADHD.
00:33:25.920 --> 00:33:29.039
That is unfortunately not happening.
00:33:29.200 --> 00:33:35.039
So people have who have bipolar are like, too bad, you have to just live live with ADHD.
00:33:35.119 --> 00:33:39.119
And the treatments we have for ADHD are some of the most effective in medicine.
00:33:39.359 --> 00:33:40.000
That's right.
00:33:40.240 --> 00:33:53.759
I want to test an impression I have you, Diane, that that the psychiatrist and psychiatrists listening to you, it seemed there are different schools of thought, different approaches, even within the field of psychiatry.
00:33:54.079 --> 00:34:00.240
Is that true that there are people practice differently, their approach to medication and treatment?
00:34:01.279 --> 00:34:06.960
And obviously, I have peers across the country that I turn to who view things the same way.
00:34:07.039 --> 00:34:18.400
And I learned from people who have the same view that I do patient-centered decision-making, treatment that people are willing to take, making sure I have the right diagnosis.
00:34:18.559 --> 00:34:24.960
So the same way that you could say, you know, all psychiatrists aren't created equal, all psychologists aren't created equal.
00:34:25.039 --> 00:34:25.280
That's right.
00:34:25.440 --> 00:34:27.199
All therapists are not created equal.
00:34:27.280 --> 00:34:28.800
And that's why you have to find the right thing.
00:34:29.119 --> 00:34:29.760
Thank God for that.
00:34:29.840 --> 00:34:30.400
And this is great.
00:34:30.800 --> 00:34:32.000
Thank God for that, go for that.
00:34:34.480 --> 00:34:39.599
Can you you really caught my attention when you talked about bipolar?
00:34:39.760 --> 00:34:45.119
So coming from business world, I have so many examples of leaders behaving badly.
00:34:46.400 --> 00:34:56.400
Then next meeting, you just swing, and things are very high energy, disruptive, and things happen, they end up apologizing.
00:34:56.559 --> 00:35:05.679
You can literally see that, and it would be in chalk that you need feedback, you need more coaching, versus something else could have gone down.
00:35:05.760 --> 00:35:07.760
You know, so bipolar.
00:35:08.400 --> 00:35:10.480
Give us a tutorial.
00:35:10.639 --> 00:35:12.639
What could it look like?
00:35:14.000 --> 00:35:36.159
Okay, well, that's a really big question, but it's it you bring up a really important point, which is I think what happens a lot, uh we really have failed the world from a psychiatry perspective in not doing more education around bipolar, what it can look like, and also quickly labeling people as having personality disorders and missing the bipolar.
00:35:36.320 --> 00:35:43.280
So I think this is why it's so important to me in my practice and the the work that I do to say look for the bipolar.
00:35:43.440 --> 00:35:48.239
It's not every under every rock and behind every tree, but it is there.
00:35:48.400 --> 00:36:02.880
There's about 2% of the population when you think of the full spectrum of bipolar, and there are different kinds of bipolar, but if you miss that, then you miss the opportunity to provide, support that patient to have the best possible quality of life.
00:36:03.119 --> 00:36:04.159
Right now, what happens?
00:36:04.320 --> 00:36:15.599
Any upset woman who goes to an emergency department with suicidal thoughts is immediately labeled as having a borderline personality disorder, which certainly exists, but not as often as bipolar disorder.
00:36:15.760 --> 00:36:21.760
And we don't have tools that we can manage borderline personality disorder like we can bipolar disorder.
00:36:21.840 --> 00:36:23.440
And that drives me bananas.
00:36:23.599 --> 00:36:27.119
No one should be diagnosed with a personality disorder in an emergency department.
00:36:27.280 --> 00:36:31.920
As you know, we need to have a longitudinal relationship with that person to be able to make that diagnosis.
00:36:32.079 --> 00:36:36.159
So a lot of CEOs will be labeled as they're narcissistic, they're antisocial.
00:36:36.320 --> 00:36:37.920
Maybe they have a mood disorder.
00:36:38.079 --> 00:36:43.360
Certainly, a lot of them aren't comfortable talking about the fact that they have a mood problem or anxiety.
00:36:43.519 --> 00:36:45.280
Maybe they're self-medicating with alcohol.
00:36:45.360 --> 00:36:46.880
So very quickly, bipolar.
00:36:47.039 --> 00:36:53.280
When you think about mood disorders, ones that affect your mood stability, I think of it as a spectrum.
00:36:53.519 --> 00:36:56.320
Way on this end is unipolar depression.
00:36:56.400 --> 00:36:57.119
You're just depressed.
00:36:57.199 --> 00:37:00.239
So if this is the happy line, you get depressed, you get better.
00:37:00.400 --> 00:37:00.639
Okay.
00:37:00.800 --> 00:37:02.320
I don't know if you can all see me.
00:37:02.559 --> 00:37:06.320
On the far other end is bipolar one disorder.
00:37:06.639 --> 00:37:09.920
You have episodes of mania, of highs.
00:37:10.079 --> 00:37:13.119
You may or may not have depressions, but that's bipolar one.
00:37:13.280 --> 00:37:14.719
You have to have manic episodes.
00:37:14.880 --> 00:37:26.800
And when you're manic, you lose insight, you can be psychotic, you put yourself at great risk because you think you're smarter and funnier and you have more money and take great risks.
00:37:26.880 --> 00:37:27.199
Okay.
00:37:27.360 --> 00:37:32.480
So the psychotic meaning you keep you're you believe that you're God, you're grandiose.
00:37:32.559 --> 00:37:32.719
Okay.
00:37:32.800 --> 00:37:37.519
So unipolar depression, bipolar one come in a bit from that, bipolar two.
00:37:37.760 --> 00:37:42.320
You have little mania, it's called hypomanias and lots of depression.
00:37:42.639 --> 00:37:45.519
We miss a lot of people.
00:37:45.679 --> 00:37:50.800
We call them depressed, they have unipolar depression, but at that, they have bipolar two.
00:37:51.280 --> 00:37:51.840
Why?
00:37:52.159 --> 00:37:57.280
Because when you're smarter and sexier and funnier, you're all your neurons are firing.
00:37:57.920 --> 00:38:00.079
I'm not coming to your office, you come to my office.
00:38:00.159 --> 00:38:01.519
There's nothing wrong with you, right?
00:38:01.840 --> 00:38:07.519
So people, when they're high, when they're in those hypomanic periods, it may be the only time they feel functional.
00:38:07.679 --> 00:38:10.800
The rest of the time, more than half their life, they feel depressed.
00:38:10.880 --> 00:38:12.480
And that's when they go and see the doctor.
00:38:12.559 --> 00:38:21.360
And then all these people between unipolar depression and bipolar two, some people call them soft bipolar, others specify bipolar in the DSM.
00:38:21.519 --> 00:38:24.320
They may not meet the full criteria for hypomania.
00:38:24.559 --> 00:38:32.800
They might not meet the full criteria for bipolar two, but my spidey sense is saying this person has a presentation of an unstable mood.
00:38:32.960 --> 00:38:35.039
Those people need to be treated differently.
00:38:35.840 --> 00:38:37.119
I want to plant this seed.
00:38:37.280 --> 00:38:41.840
So some of the clientele that I work with are in the startup founders.
00:38:42.880 --> 00:38:49.599
Working with them when they are in the bipolar spike, they are amazing, high energy, high creativity.
00:38:49.760 --> 00:38:52.000
They run, run, run, and then they crash.
00:38:52.079 --> 00:38:54.400
And when I talk with them, they said I just had burnout.
00:38:54.719 --> 00:38:59.199
Burnout is not a clinical term, it's an occupational medicine term.
00:38:59.840 --> 00:39:09.360
And they chuck it to burnout, and then I see periods of leaders behaving badly, adultery, a lot of drinking, and so on.
00:39:11.920 --> 00:39:15.519
Everybody tolerate them because they get a lot of work done.
00:39:15.920 --> 00:39:22.880
A lot of work done, and a lot of medication, self-medication, ketamine, you know, like uh magic mushroom and so on.
00:39:23.039 --> 00:39:35.679
But what I want to digress is that the future podcasts with you just about how bipolar can be fuel for amazing performance at the high cost to the individual and their team.
00:39:35.840 --> 00:40:12.480
But it's a separate topic that the to their to the individual, to their team, to their family, bipolar disorder has a higher rate of suicide, a higher rate of completed suicide, high risk of addiction, so self-medication, and people who, you know, they've got more energy, they don't need to sleep, they feel like, you know, I get an hour or two and I feel like I've slept all night, I can go, go, go, but invariably followed by a crash and during that go, go, go time, irritable, taking risks, putting other people at risk, putting their business at risk.
00:40:12.719 --> 00:40:13.920
So it's really important.
00:40:14.000 --> 00:40:16.400
And I'm not saying that's every situation like that.
00:40:16.559 --> 00:40:25.840
What we need is use clinical scales, have education so people know when I see someone like that, maybe we need to stabilize their mood.
00:40:26.000 --> 00:40:29.039
Maybe they need to make sure that they don't have that diagnosis.
00:40:29.280 --> 00:40:35.039
What the problem is, is all the old drugs that we used to use, people would feel zombified.
00:40:35.119 --> 00:40:36.159
They'd feel flat.
00:40:36.320 --> 00:40:50.719
And I remember a woman who was actually on my podcast psyched up talking about this and saying, but when I first met her, saying, look, I don't miss the alcohol, I don't miss my kids being angry with me, I don't miss all the trouble I was in.
00:40:50.960 --> 00:40:52.880
But man, I miss my highs.
00:40:53.119 --> 00:41:03.199
Because when you're depressed all the time, having those periods of up when you feel on fire, it's hard to lose those because the rest of the time people feel depressed.
00:41:03.440 --> 00:41:03.840
That's right.
00:41:03.920 --> 00:41:11.119
This is such an amazing topic about you're right, people who feel they lose their edge, you know, once they come down.
00:41:12.800 --> 00:41:17.119
I want to change the topic to uh treatment resistant depression.
00:41:17.280 --> 00:41:19.039
And this topic is personal for me.
00:41:19.119 --> 00:41:31.360
I have two dear colleagues that they were diagnosed, so they were successful professional, and then they quit their job, and I saw them a few months later, they looked really haggard.
00:41:31.519 --> 00:41:34.880
And I've having done my clinical training build with psychiatric.
00:41:35.440 --> 00:41:37.440
I can see when you're over medicated.
00:41:38.480 --> 00:41:47.840
They said I've been diagnosed with clinical, treatment-resistant depression, and they were going to inpatient, outpatient, multiple medications.
00:41:48.559 --> 00:41:53.440
But I know about those two individuals, they grew up in a heavy trauma families.
00:41:54.559 --> 00:41:59.440
And I was keeping uh wondering, did they get the right treatment?
00:41:59.679 --> 00:42:08.400
Because it seemed there were a lot of talk therapy, a lot of medication, including uh what is that uh TMS that you know the RTMS.
00:42:08.800 --> 00:42:09.199
That's right.
00:42:09.760 --> 00:42:15.280
But I felt they can be helped, but are they seeing the right clinician?
00:42:16.000 --> 00:42:19.360
So as a colleague, I didn't go there, I didn't want to lose faith.
00:42:19.519 --> 00:42:24.159
But what is your take on treatment-resistant depression?
00:42:26.079 --> 00:42:47.440
So there's no universally agreed upon like the DSM or the ICD 10 treatment-resistant depression, but most people think about treatment-resistant depression as individuals who have depression symptoms, despite trying a couple, at least a couple of antidepressants at an optimal dose for an acceptably long period of time.
00:42:47.599 --> 00:42:48.880
See how vague that is?
00:42:49.119 --> 00:42:54.159
There are a lot of people who have difficult to treat depression, but it's not necessarily treatment resistant.
00:42:54.320 --> 00:42:57.440
They haven't just found the right treat for that individual.
00:42:57.599 --> 00:43:05.119
Uh, we miss a lot of comorbidities, as you've said, with ADHD, uh, PTSD and depression just ride together.
00:43:05.199 --> 00:43:13.119
So missing trauma, and there are different approaches that you can take to trauma if there was a clear trauma history that can be quite helpful.
00:43:13.280 --> 00:43:25.440
But I do have, and you know, I can think of two patients right now who have had very biological depressions, both of them quite young, both of them required ECT to get better, electroconvulsive therapy.
00:43:25.679 --> 00:43:45.360
I write a lot about that because there is a lot of stigma around what is probably the most researched treatment, and certainly in psychiatry and maybe in of all treatments, because of the fact that you're electrocuting someone, but it is the gold standard for treatment for depression and very, very safe.
00:43:45.760 --> 00:43:53.920
But it's difficult to get, it's expensive, and there are some side effects related to short term people get very frustrated with memory loss.
00:43:54.159 --> 00:43:56.480
So I've had lots of patients who have had ECT.
00:43:56.559 --> 00:43:59.840
These women got better, they've lived their lives, they've had families.
00:44:00.159 --> 00:44:02.880
Families and perimenopause hit.
00:44:03.199 --> 00:44:11.440
Both of them had lowered or stopped their medication, thinking, you know, I'm all better, despite the fact that I begged them, please don't do that because they had been so ill.
00:44:11.679 --> 00:44:17.280
And both of them right back to at perimenopause to very severe depression.
00:44:17.519 --> 00:44:28.800
Now, both of them, the best course was probably to go right back to ECT because they had such a treatment-resistant course years ago, but they didn't want to because they don't ECT is not fun.
00:44:28.880 --> 00:44:33.679
You have to go into every when you have the treatment, you have to be asleep, all this sort of stuff.
00:44:33.760 --> 00:44:35.119
There's a burden that comes with this.
00:44:35.280 --> 00:44:36.559
So we've tried other things.
00:44:36.800 --> 00:44:41.119
Ketamine has some incredible data, and but it hasn't worked.
00:44:41.199 --> 00:44:43.440
And they both ended up going back to ECT.
00:44:43.599 --> 00:44:47.199
So those to me are truly treatment-resistant depression.
00:44:47.440 --> 00:44:50.079
Just an antidepressant with an add-on treatment.
00:44:50.159 --> 00:44:53.760
Sometimes we use antipsychotics who have that, it's a terrible name.
00:44:54.000 --> 00:44:58.400
I wish we didn't call it that because neither one has ever been psychotic.
00:44:58.559 --> 00:45:01.679
But they, and so that they're that's stigmatizing again.
00:45:01.760 --> 00:45:04.400
But these add-on treatments, it can be very effective.
00:45:04.639 --> 00:45:10.719
But for these two, they have extremely treatment-resistant illness and only ECT has worked.
00:45:10.800 --> 00:45:14.559
One of them's better now, the other one is having their treatment now.
00:45:15.039 --> 00:45:21.360
So what I want to say about treatment-resistant depression is it's an easy label to throw around.
00:45:21.519 --> 00:45:24.719
You have to make sure you haven't missed something in the diagnosis.
00:45:24.880 --> 00:45:26.159
But those people do exist.
00:45:26.239 --> 00:45:32.079
And I think a lot of their care providers are simply trying to give them some kind of relief from their pain.
00:45:32.320 --> 00:45:32.639
That's right.
00:45:32.719 --> 00:45:33.920
And thank you for mentioning that.
00:45:34.079 --> 00:45:48.719
Then my boat of colleagues that they mentioned that I was thinking now you have one more label that really doesn't make sense, is not clinical, and it deprives you of an explainability that seeing a bigger picture.
00:45:49.599 --> 00:45:54.800
As we bring to a close, I mean, time really with you flew by.
00:45:55.119 --> 00:45:56.320
It flew by, didn't it?
00:45:56.480 --> 00:45:56.880
I know.
00:45:56.960 --> 00:46:02.960
I'm just thinking, we're just starting that there are people who listening to this podcast, to this YouTube.
00:46:05.119 --> 00:46:10.159
What do you want to tell them as part of your message?
00:46:12.079 --> 00:46:21.920
The reason that I wrote my book, This Is Depression, was for patients and their families, for people's supporters, because it's not always your family that is your greatest supporter.
00:46:22.079 --> 00:46:27.760
So for the individual who's living with the illness and also the people that are surrounding them.
00:46:27.840 --> 00:46:31.519
And that's because I was spending all of my time trying to educate.
00:46:31.679 --> 00:46:40.800
But when you're really depressed, when you're super anxious, when you're struggling with a bipolar episode, it's really difficult to hear and remember what I'm saying.
00:46:40.960 --> 00:46:49.039
And it's even more difficult to remember that and share with your family or your supporters who are saying, Why are you on all this medication?
00:46:49.119 --> 00:46:50.000
Why are you taking this?
00:46:50.159 --> 00:46:51.599
Why is she changing this again?
00:46:51.760 --> 00:46:52.800
And I understand that.
00:46:52.960 --> 00:47:00.079
So two things I used to always and I always try to get family members to come in, whoever your supporter is, who do you love?
00:47:00.239 --> 00:47:02.239
Should be one of the first questions you're asked.
00:47:02.320 --> 00:47:06.000
And then when will they come in so that they can understand who I am?
00:47:06.159 --> 00:47:08.159
I don't have horns and a icky tail.
00:47:08.320 --> 00:47:11.679
I'm someone who's really here as a supporter as well.
00:47:12.079 --> 00:47:17.599
But I also want them to understand why we're going through this path so that they can help.
00:47:17.840 --> 00:47:20.159
The other thing is stigma lives.
00:47:20.400 --> 00:47:29.679
We like to think that it's better for mental illness now, but you know, and younger people certainly talk about it more, but it still lives out there and not just in little meme groups.
00:47:29.920 --> 00:47:32.719
It lives in medicine, it lives in psychiatry.
00:47:32.880 --> 00:47:40.719
So I think that well-meaning people can continue to stigmatize their own patients by the way that they approach their mental illness.
00:47:40.800 --> 00:47:46.079
And so the whole book was really focused on mental illness, it is real.
00:47:46.239 --> 00:47:49.920
It's not all in your head, but of course, everything is all in your head.
00:47:50.079 --> 00:47:51.920
And so please don't give up.
00:47:52.000 --> 00:47:53.360
There's always a path ahead.
00:47:53.599 --> 00:47:54.960
There was a beautiful.
00:47:55.199 --> 00:48:02.079
And then to build on that, one of the reasons for this conversation, you're not depressed, just unfinished.
00:48:02.880 --> 00:48:07.440
Really, these conversations are about the power of explainability.
00:48:08.239 --> 00:48:15.199
Coming from my years of pain, thinking about my family, I just felt that I will die depressed.
00:48:15.280 --> 00:48:18.960
And it was a very depressing feeling to know that I was contemplating suicide.
00:48:19.360 --> 00:48:24.559
It was when I did my own work, research, realized that there are patterns of existence.
00:48:24.719 --> 00:48:26.400
Depression has a structure to that.
00:48:26.639 --> 00:48:28.079
Anxiety has a structure to that.
00:48:28.239 --> 00:48:31.760
Once you understand that, you can reverse engineer.
00:48:32.239 --> 00:48:38.639
My healing came through understanding that these are not illnesses confusing, but there's pattern.
00:48:38.960 --> 00:48:44.880
Once you know why they shape, what sustains them, and how do you can reverse them?
00:48:45.119 --> 00:48:45.519
Dr.
00:48:45.599 --> 00:48:47.519
McIntosh, this was very helpful.
00:48:47.679 --> 00:48:48.559
Thank you so much.
00:48:48.800 --> 00:48:51.199
All the power to you, and I will see you again.
00:48:51.440 --> 00:48:52.400
It's a real pleasure.
00:48:52.559 --> 00:48:53.440
Thank you.