Doctors on depression - How to approach your own mental health - NHS A to Z - Dr Gill

hello ladies and gents and welcome back to this next episode of the a to z of the nhs we're dealing with depression today a particularly important subject to my heart because i see it with an awful lot of patients at work but feel that it's something that most people will experience in some way shape or form in their lives so hopefully people will find a benefit hidden in some of the conversations between myself and andy here but we're starting off with the medical news things that have caught my or and his attention over the week and something that's piqued my interest after our previous video on bmi is that recent studies concluded that intermittent fasting which had actually been considered to be quite a positive approach to weight loss particularly if you're for example having your last meal at five six o'clock in the evening and not breaking your fast having breakfast until eight nine o'clock in the morning has been shown to be no more effective at weight loss than simple calorie restriction and other similar types of diet which is i'll be honest a surprise to myself however what the researchers have commented is that intermittent fasting combined with exercise may produce a more beneficial outcome not only to weight but also to health and i think that particularly for a video where we're about to talk about depression is very important people can often get hung up on weight as a pure number whereas focusing on health is going to give you a much better dividend in the end whether or not that's benefits to your mental or physical health purely focusing on the number of weight that number that is weight can actually be very detrimental to someone's mental health and hopefully we'll explain some of the reasons why now so thank you for staying this far and i hope you enjoy our chat on depression hello and welcome back to another a to z of uh the nhs we're going through the letter d today and if you just come over from our vitamin d video you've seen our slightly clumsy segue into depression depression i think depression with diabetes is probably the disease of our time and and that's because it's common and it's serious um so tell me a little bit james about what depression is how common is it etc etc well i think perhaps even before we talk about depression we need to actually say what what is mood and i'm not going to go on metaphysical with you but i think we just need an idea because we all feel down from time to time you know our moods change um one way of viewing it is our emotions are the weather so you're gonna have a bright day you're gonna have a rainy day the following day next day it's blustery those things will change from day to day our mood however is the climate so you know we could say in rainy britain that uh we have a relatively depressed mood but that mood is you know that's that's what we're having as the climate overall and we want to know that with a patient somebody says yes i'm feeling really low fine tell me about that how long have you had it what's how would your friends describe you well actually i'm normally absolutely over the moon it's just you know felt a bit down this week and that's a patient who i'll probably want to listen to their worries but i may not go towards that label of depression moment i might just go oh perhaps we've got a bit of an emotional low state or low mood we'll review things so there's a difference between just having a low mood today and depression then is that right absolutely yes depression is a pervasive low mood or a sadness that that is your defining feeling when we ask how are you you know your default is i'm just a bit low i'm a bit sad you know and there's absolutely no problem with having those feelings and saying those feelings assuming you're going to talk to someone and get some help with it before you tell me about how common it is what it's due to etcetera what is available out there for the public who can they refer themselves to for example well i would always say that if you are unsure and if you're worried about your mood talk to your doctor because we're able to help assess what we need to do so as i say somebody who just has a bit of a low mood we might need to say okay well these things happen and we'll keep an eye on you review in a couple of weeks time and talk about a few things that maybe they could do to improve their quality of life conversely so if we look at somebody like stephen fry we may have a patient who finds their moods change significantly so one day they are feeling suicidally depressed and then you know that terrible low mood lasts for weeks and weeks but then that will cycle and they will have weeks and weeks where they are you know invincible that they feel they've got superpowers that they could run a country and there we might think maybe this isn't a straightforward low mood but maybe this is a bipolar disorder that they're going from one extreme to the other so always talk to your doctor and we'll you know give you advice about what you may be able to do yourself and there's lots of apps that people can use there's self-help groups there's a huge range of options but we need to find the right one for you i think it's fascinating that celebrities famous people out there now coming forward and telling us about their depression and their mood i have a lot of time for the royal princes and footballers like peter crouch and other people that are coming forward and admitting on television that they have a mental health problem they have depression and i think we as a society must be progressing because even when i was a junior doctor in the middle eighties people didn't really talk about their mood they didn't talk about mental health they didn't talk about depression like they do now no and i still think we've got a long way to go i will deal with a patient who has you know low mood and as far as i'm concerned they are depressed we've done all the work out which we'll go through in a moment but i offer them so right you do have a moderately or severely reduced mood we need to try and do something for you and we they may be not keen on medication so we'll go around down a few non-pharmacological routes and unfortunately sometimes those don't work and i suggest putting forward antidepressants because it is important that this is a union between the doctor and the patient i can't say you're going to do this we have to work together for it but you'd be amazed the number of people who initially say no i i don't want to go on antidepressants what i say to them is if you broke your leg you wouldn't object to having a plaster cast and a pair of crutches would you your mind is sick at the moment your brain is ill so let's give you the pharmacological equivalent of a crutch and some plastic paris will help your brain to heal will give you the chemicals that are maybe running very low with you at the moment and let things return to normal will support your mood to improve and then like the plaster cast like the crutches will begin to take them off and hopefully you'll go back to running and having your life without the medication and there are some tablets called ssris now aren't there they're said to be very effective do you prescribe them we've got a range of medications and i think that each medication needs to be given to the patient as they need so looking at the ssris or the snris as well there's a medication called sertraline and the way i like to describe this is this is an anti-anxiety medication that has antidepressant benefits conversely we have a medication called citelapram that is an antidepressant that has anti-anxiety benefits we've got some of the other more complicated medications like mitazepine which has anti-anxiety benefits antidepressant benefits but also has you know benefits for sleep health and also benefits on appetite but what we may end up doing is focusing on sometimes we have to prescribe for what the patient needs anxiety versus depression and sometimes we have to prescribe for what the patient is able to tolerate in terms of side effects so a big example on that and you know we're going to talk about adult themes because there's in the same way that dealing with mental health and depression we should also appreciate that sex is an appropriate important part of life some patients don't get on with sertraline because their sex drive goes and they have difficulty orgasming and that can have as many problems for their mental health as the initial issue did and the patient might say i don't know what to do i'm feeling better but it's called the medication is causing me other issues and then we'll open the bnf and we'll find another approach for them i must admit i don't often diagnose depression or start treatment i do sometimes and i'm quite keen on a drug called duloxetine which is an ssri the reason i use it is many of my patients has diabetes and we mentioned that in the previous video causing neuropathy causing pain in their legs and sometimes duloxetine can break the cycle of depression and pain in the legs have you ever used it for that purpose specifically for that i use it not infrequently and with a lot of medicine actually i like the idea of volumes and i've got one lady who has really nasty peripheral neuropathy from her diabetes we've given the diloxatine and it hasn't resolved the issue but she's described it as turning down the volume of the pins and needles so she's able to ignore it and i do wonder how much of that benefit is solely because it's reduced the sensation of paresthesia and how much of it has also helped her mood so she's able to resist the paresthesia and ignore it more so i think we're definitely getting a synergistic effect there tell me a bit about how ssris work isn't it something to do with certainly there are several hormones that affect our mood so we have serotonin which is a positive mood hormone and then we have oxytocin as another example that sort of the love hormone we have dopamine the happy hormone so different ones have different effects but the two medications we've talked about there the ssris and the snris actually if we look at what those acronyms mean will tell us a lot about it so the ssri the selective serotonin reuptake inhibitor basically means that it's going to keep more serotonin in the the parts of the brain where we need it so the patient's mood improves because we're giving them more of that happy hormone conversely the snri then we've got serotonin and noradrenaline reuptake inhibitors again we're trying to make sure there's more of the hormone where they need it in the brain at that time are there any non-tablet therapies you could prescribe i've heard there are some counsellors called iaps is that right you can refer a patient to now i'm just going to push back ever so slightly on that i am fond of helping the patient in whatever way they need and i like a multi-faceted approach i like a bit of this a bit of that all on together and then we see what works so with the patient and as you've said the iaps improving access to psychological therapies is a champion way of helping people who've got a bit of a low mood where we've not actually said they have depression and i think this is probably worthwhile time for us to look at how we say you have low mood or you've got depression csando so one of the things that we can use to assess how the patient's mood is is something called the phq-9 scale have you used that in one of the hospitals can't i have tell me about it okay well that's a nine-point scale that helps us look what the patient's mood is but the crucial thing is it has to be over the two last two weeks going backwards so that's going to help us differentiate is it the patient having a problem with their emotions short term or is that a problem with their mood the climate the long term so in terms of those those questions we want a full point scale with them so each of those questions which i'll go through in a moment i need to know if the patient has experienced them not at all several days more than half and nearly or nearly every day and actually you can have a look at this phq's nine scale online it's a free tool and will allow you to assess your own mood status if you wanted to so the things i'm going to ask that patient have they had any little interest or pleasure and things that they would normally i mean so for example everyone enjoys a favorite tv show if you no longer care about it that's something i'm going to be worried about have they actually felt down depressed or hopeless yes we know that emotions are short-term but we're talking about the two-week period here have they had any trouble with sleep i mean we've all been a bit low and we get tired so that tends to go both ways some people with depression sometimes can't sleep and sometimes they're sleeping too much and that might suggest also the next question how are their energy levels have they had low levels of energy we tend not to get hyper with depression but certainly we can get that low level what's the appetite and that will go both ways is a person comfort eating eating huge amounts i know when i've had mood issues i've ended up you know eating huge amounts or conversely do you not want to eat at all and sometimes we can end up patients losing a lot of weight because they're mood again going through this nine point list i think this one's quite appropriate do you have difficult difficulty with concentration you know that you can't read a book anymore you can't carry on a conversation you can't watch your favorite tv show what are you like in terms of the overall person so are you slow and not really interested and literally moving slowly or are you a little bit more like me you know fidgeting and picking your nails and biting and twiddling your hair and things like that and then the final question and this is the one that i think is often the most upsetting for patients but also the most revealing and i ne i always make sure i preface this with the patient that i'm going to ask them a hard question have they had any thoughts about hurting themselves or they might be better off dead and depending on the answers to those questions we can score them to say that they've got a moderate low mood where we may say right you're definitely going to benefit from psychological therapies talking therapies eye apps you know talking about cognitive behavioral therapies maybe just straightforward exercise and walking more then we've got the moderate depressions uh moderate low mood where definitely the phq nu the iaps the psychological therapies is needed but maybe the patient will benefit from some anti-depressant medications the two working synergistically and then the moderate severe ones where i want to give them everything possible and i'll be suggesting strongly i'm still letting the patient make the choices but i'm suggesting very strongly that we start a low-level antidepressant again i expect most people to be resistant to it but i say we start a low-level antidepressant and review them in two weeks time and see how they're doing if they've gotten on with it excellent we can look at building but if they haven't then we'll look at why and what we can do to go forwards this is really fascinating and it actually reactivates some dark memories i have about seven years ago i was pretty unwell i didn't really know what was wrong with me i was very agitated and angry all the time and fortunately my amazing wife arranged an appointment with my family doctor my gp i thought it was a medical problem i was losing weight in fact viewers i got down from my normal chunky self by a factor of about five stone i lost five stone in weight and when i went to see my gp he said to me andy the problem is depression and i must admit it sounds strange because i'm a doctor but that had not occurred to me do you see depression in professionals like me and other professionals out there i'm going to be really clear of that about this if you are a person then you can be depressed i see depression in all walks of life and it is somebody has put themselves in a position where they've ended up depressed someone has had depression because of a situation they have found themselves in somebody has just depression and no reason why and sometimes we'll have a discussion with a patient and say i have no reason why i feel like this technically i have a fabulous life i've got no money worries i love my job i love my wife i love my children and i don't want to get out of bed in the morning and i hate myself and i have had dark thoughts about throwing myself in front of a bus and it's terrifying me and i haven't a clue why and there is nobody should blame themselves for their mental health and my argument is you would not blame yourself because it was raining outside thus you shouldn't blame yourself for how your brain reacts to things the end of the story was the gp my fabulous gp took charge started me on an ssri in fact it was duloxetine and slowly over a period of months i slowly got better and slowly regained all that weight so the story ended happily but i thought i would share it with you viewers out there just to realize that none of us are immune from depression and other mental illnesses so what about the patient who gets worth change you've tried iapped you've tried ssri you've changed the ssri what do you do next it's going to depend on how the patient is getting worse it may be that we need to increase doses and we might need to tolerate side effects that previously they've not been willing to but assuming we go down that line and we're still having trouble with the patient or something that worries me critically that the patient is taking their medications they're trying everything but they're saying to me i am still frightened that i won't be able to resist the urge and i might try and kill myself i mean that's a strange conversation to have with somebody than being you know very much present in the room and saying i don't want to but i'm frightened i might hurt myself then i'm going to move to secondary care and we talk to the psychiatrists or possibly if i'm worried that the patient is going to hurt themselves today somebody coming in and gripping their chair doctor helped me you know i tried to kill myself last night and i'm concerned it'll happen again then there is the crisis team that will able that will be able to get help to that patient within hours and it may be that they're going to give some specialist only medications to try and bring their mood under control so how do you get hold of that crisis team how do you get them to the patient's bedside or whatever so there is a direct line that as gps we have access to the central booking service and they're able to help stratify because obviously everyone calling that line as a health professional is very worried about that patient and they will be able to say right send this patient to the any department and we will meet them there you know okay you're on maybe on maybe i'm on a home visit they may say right call the police and we need them to help take the patient to the a e department because collectively we're so worried about them they may say has the patient got somebody at home and do they feel safe with that person brilliant send them there and we will contact them within four to six hours that stratification helps them give the acute treatment when needed and if they get up to the hospital and the crisis team assesses them and the crisis team thinks they are really ill but the patient doesn't want treatment maybe is frightened of treatment and then refuses treatment what can they do or you do about that thankfully after very intense very cautious discussion we have very few patients that actively say i don't want treatment but if we look at the example for bipolar perhaps and we flip it that the patient feels that they have superpowers the patient may not be aware that they need treatment and in some very rare cases then two doctors are able to assess the patient and they may be able to section the patient so take away their freedoms in order to force um treatment on that patient but that is very rare and those patients can be quite distressed by it but so far i have failed to meet a patient that has been sectioned that once they've had the treatment and is feeling better is not immensely grateful for that and sometimes quite apologetic for the names we get called doing it and i think the word section comes from a section of the mental health act doesn't it yes and that's why we use the phrase section and as you say i think it's used uh quite rarely on patients tell me a bit about the section though if the patient is sectioned does that section last forever it lasts for as long as the patient needs and patients can go in through voluntary sections they say right you're saying i have to go into the hospital i have treatment i've heard that i will go into the hospital so they've not had that formal section and that many ways is a very good mental thing because the patient knows that they can leave so they're there of their own volition but sometimes as i say if the patient isn't aware of what's going on then we can have a timed section sometimes they can last for you know a long period of time until the patient is well enough to be not a risk for themselves or others and i think you should all be reassured that there are checks and balances in the system i think there's one that cuts in at four weeks after one of the sections which means it has to be reviewed by independent people so it's not possible for the state for doctors or people like me and james to lock people up against their will and throw away the key there are checks and balances in the system isn't that right absolutely and that's why even for the initial section you must have two independent doctors to do it it's why i was never able to section my best mate even though i deserved it what i'd like to know is do people with depression get better yes simply they get better however like somebody that has diabetes they may have a perfectly normal life with treatment that patient may get better they may have no ill effects with their mood at all and they may not need any treatment at all now once they've overcome their illness conversely some people may need to see a counselor intermittently the way i describe it is for a bit of a tune-up to make sure that they are you know able to express things and think about that where who can you honestly say and some people are very lucky that they have these very close relationships but there are i imagine few people are lucky enough to have someone they can truly talk about not their worries or their fears but their darkest thoughts in a safe environment and that's where the counsellors can be really beneficial to long-term mental health because it allows a safe space for those to be explored and address sometimes depression is not clear-cut somebody may be coming in depressed because they have anxieties and the anxiety may be the thing causing them to be depressed and we try and treat the depression and it doesn't improve because we haven't dealt with the root cause and that's often where again the counseling the iaps but the longer part of their health comes in because if we can find or address the causes then like addressing you know somebody having an infection if we find the root cause and treat that then they will hopefully recover and do you see any interaction between chronic medical or surgical conditions and chronic mental health conditions absolutely and that's again where the counselors and psychologists come into it i i like to feel that i can empathize with my patients that i can try and help them understand where they are but i honestly don't think that i could genuinely put myself in the position of somebody who's had their legs amputated and is no longer able to walk in the same way they could do and helping somebody come to terms with their health status is going to be a vital part of helping them with their mental health note i haven't said with their mental health condition because you may have a very strong person that deals with whatever their medical issue is and doesn't develop a mental health problem but we still want to help them with their mental health to ensure that problem doesn't come in the first place so i just want to give a public health thing as we wrap up the depression here we've talked about some very emotive terms and emotive things particularly people you know potentially you know not wanting to be here anymore and ending their own life if you have felt anything like this any worries please talk to your doctor okay or if you're troubled about these things now we're going to put a couple of numbers on the phone on the screen now for um uk and because we know there's a lot of american views some american numbers as well if need be please call those numbers um