Podcast: How To Support Someone With Depression

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks, thank you so much for joining today, wherever you are, whatever time it is there, whatever the weather looks like to tune into our chat about ways to support a loved one with depression.

I’m Jenn Kearney and I’m joined today by Dr. Chris Palmer. And before we jump into things, just wanted to provide a couple of stats so you can realize just how common depression really is. First and foremost, it’s the leading cause of disability in the United States in folks between the ages of 15 and 44.

And in 2016, the National Institute of Mental Health estimated that about 6.7% of the US population had depression. 2016 was five years ago pre-pandemic, so you can only imagine it’s gone up from there.

Because after all we are all dealing with unprecedented times, difficult situations and unimaginable grief and loss. Yet even though we’re all going through collective mourning, sadness, COVID global crises, there’s still a lot of stigma around depression.

So we are here today to talk about how folks with depression, “can’t just snap out of it,” how we can best support people that we care about, ways to navigate the dark days of depression, and sometimes more because if you tuned in before I pressed record, Chris and I sometimes go off track in some really delightful ways.

So if you are unfamiliar with Chris, you should get ready to be amazed by all the knowledge he has on so many subjects. Because Dr. Palmer is internationally known for pioneering the use of the ketogenic diet in psychiatry especially in treatment resistant cases of mood and psychotic disorders.

And he’s currently serving as the director of the Department of Postgraduate and Continuing Education at McLean Hospital. So Chris it’s really nice to see you thank you so much for joining me, cause clearly you’ve got a lot going on based on your bio alone.

So I wanted to get started by asking, what are some of the most common symptoms of depression that we might be able to identify either in ourselves or in a loved one?

Chris: That’s a really good question. And when it comes to depression there isn’t just one type and the symptoms can actually be very different in different people. And it’s really important to recognize that, and I’ll tell you a quick anecdote after I tell you the symptoms.

So there are nine symptoms of depression, depressed mood is one of them, the others are changes in sleep, you can be sleeping too much or too little.

This thing called anhedonia or decreased interest in things is when people kind of lose interest or lose passion for life, say nothing is interesting, nothing is enjoyable anymore, even things that used to be enjoyable are no longer pleasurable to people.

Another one is feelings of guilt or worthlessness, low energy, poor concentration, changes in appetite, and again it can go either up or down. Some people can gain weight when they’re depressed, other people can lose weight, and yet others don’t have any changes in appetite.

And then there’s a thing called psychomotor slowing, which is really just, you can tell by looking sometimes at people that they’re depressed. Cause they’re just slow moving, they’re kind of slouched over, their head is might be hanging low, it looks like they might be sick with a cold or flu or something, they just they don’t look well, and you can tell just by looking at them by the way they move.

And then the last one are thoughts of suicide or thoughts of death. And sometimes those are different. So sometimes people just become preoccupied with like, what’s it going to be like when I die, or I can’t wait to die, I really want to die.

If they’re religious, they might be thinking, you know, it’s my turn, I hope God takes me soon. Whereas if you ask them are you thinking about hurting yourself? Say oh no, no, not at all, and yet they’re really preoccupied with dying. And so those are the symptoms.

So one of the big things I want to point out to people that it can be confusing to a lot of people. Some people will, if you ask them are you depressed? When they are clinically depressed they will say no absolutely not.

And they will argue with you tooth and nail, I am not depressed I don’t know what you’re talking about I have no depression. So the other question and they’re not lying to you, some people think well maybe they’re just out of touch with their emotions and it’s not necessarily that simple.

It may not be that they’re out of touch, they legitimately may not be aware of feeling depressed. The other symptom that they would have to have if they don’t have that one is this thing called anhedonia, which is loss of pleasure in things.

And so if somebody says no to they’re not depressed, you can easily follow it up with, do you feel like life is just blah? Like life is just become a chore or just monotonous nothing is enjoyable anymore, everything is kind of just challenging or burdensome or just boring and monotonous.

Like, there’s no there are no ups and downs anymore. And if they do have clinical depression, they have to say yes to one or both of those things.

And then you kind of go through the checklist of the other symptoms, and if they get five out of nine of those, and there aren’t clear reasons for them to have those symptoms other than depression, then major depression is diagnosed.

Jenn: If you think that you or someone you care about might be struggling with depression but they don’t have a professional diagnosis, are there any of the behaviors that you’ve described or others that you might think of that might be a real red flag that somebody needs help?

Chris: It’s a really important question but it’s actually kind of tricky to answer and I’m focusing on the part of where somebody needs help. So depression actually can come and go.

And in the majority of people on the planet, people can get clinically depressed, they can have clinical depression that lasts greater than two weeks, and it can go away on its own, it can run its course.

And we don’t fully understand why in some people it goes away spontaneously and other people it can become a lifelong chronic debilitating disorder, we really don’t understand that yet.

But so in terms of getting help I’m sure we’re going to get to this, because getting help is difficult, accessing mental health care is a challenge, even before the pandemic it was challenging. Insurance companies often won’t cover the sessions, a lot of times you have to pay out of pocket.

Even if you have cash and you’re ready to pay out of pocket, it can be very challenging to find a clinician who’s taking patients, let alone a clinician that is a good fit for you that actually you get along with, that you respect, that you feel like this person is going to help me.

And so it’s difficult to say I would say the cardinal symptoms in my mind of when somebody definitely needs help number one, if their safety is in danger.

So if they’re thinking about hurting themselves or suicide, or if they’re even just preoccupied with death, that is a clear medical emergency and that person needs help urgently. If the other big kind of bucket that I put in when somebody definitely needs help is when they are no longer able to function in life normally.

And like, so when the depression is so bad, that it’s interfering with their ability to function in life, and that could be interfering with their ability to go to school and get similar grades to what they’ve always gotten. It could be impairment in their ability to go to work and perform at work in a usual manner.

Certainly if things are so bad that somebody is failing courses, or if somebody is, you know, being threatened with termination at work because they aren’t showing up for work, or because their productivity has plummeted because they just can’t concentrate, they’re like preoccupied, ruminating all the time.

I would say those are pretty close to medical emergencies as well. I mean those are people who desperately need help and they need professional help. Where to draw the line of like at what point do you kind of give it more time give it more time, is difficult if not impossible to answer.

And you know, the national statistics in the United States prior to the pandemic, 40 to 50% of people with serious mental disorders this includes schizophrenia, bipolar disorder and chronic depression major depression.

40 to 50% of people are getting no mental health care at all, that is how difficult it is to get mental health care. So it’s hard for me to say, everybody should run out and get a therapist if they’re experiencing even mild depression.

It’s great to say, I’m not going to stand in anyone’s way go for it, if you feel like you’d want help, feel like you need help and you want to try to get help absolutely go try to get help. But the sad reality is actually finding help is going to be really challenging for a lot of people.

Jenn: I’m feeling torn because I have two questions that are completely relatable to what you were just talking about, I’m just going to go with this one first.

The people who are most quiet about needing help are the folks who need the most help especially if you’re adding other co-occurring disorders like OCD into the mix. And I know you just acknowledged that not everyone has access to care, and we’ve had a really hard time, we had a mental health crisis pre-pandemic.

So do you have any advice for what folks can do to have easier access to mental health professionals or any suggestions for resources that might provide easy to access mental health care?

Chris: I will give you my usual list. So there is no one place to go unfortunately, and so that’s why I’m going to give you kind of a list and a comprehensive thing. So first and foremost, when somebody is really depressed they are impaired, they are already down and out.

They are struggling with self-esteem oftentimes not always but oftentimes, they might be struggling with their confidence, they may be struggling with motivation and energy to do anything, let alone this challenging task of now I need to find a therapist when or a psychiatrist when it’s next to impossible to find one.

How many rejection phone calls can I make before I just give up and say it’s hopeless? So if you know somebody with depression, one of the most important things you can do is be an ally and an advocate and make phone calls, and do these things that I’m going to recommend you do to try to find a professional.

Because it can be challenging for the best of us even when we are completely healthy, and so when somebody is down and out and impaired, suffering from moderate or severe depression it can feel overwhelmingly difficult or hopeless.

The things that I would recommend you do number one, network, network, network, network. So anybody you know that you feel comfortable talking to about this, ask them do you know somebody? Do you know a good psychiatrist? Do you know a good therapist that I that my son could go to, that my husband or I myself or whatever.

Talk to your network of care providers, so that includes your primary care doc, your family physician, your OB/GYN, your child’s pediatrician, any of those people. Ask those people. They hopefully will have some referral sources that may be able to hook you up with a mental health professional.

The next step would be to just Google or look up in some directory, mental health clinics, mental health hospitals in your service area wherever that is, however far you can drive, and now with remote visits it can get a little bit easier even, but sometimes people have to stay within the state lines even though a lot of appointments are remote.

But you can Google any mental health hospitals near you, mental health clinics, other things near you. The national association or National Alliance for Mental Illness, mentally ill, NAMI will have some resources.

There are others that will have referral resources, Psychology Today for instance has an online therapist referral service, where you can just put in what you’re looking for, put in your location, and it will show you some therapists that might be available in your area. So those are some ideas.

Again, be prepared for some dead ends, be prepared to talk to your family practice doc and get the answer. Well we can get you in this clinic, but it’s six months waiting right now, and it’s going to be like six or seven months before you get an appointment.

And then people are going to feel like whoa, we’re having a crisis right now today we can’t wait six or seven months. The person is not sleeping, the person is suicidal, whatever like that’s not acceptable, don’t take that as an answer.

And if things are really severe and you are desperate, walk-in clinics or emergency rooms may be required unfortunately. So if somebody is really at risk of harming themselves, I would not hesitate to take your loved one to an emergency room and make it their problem to help you find a psychiatrist now.

And they will not be able to discharge you until they help you. They can’t give you a referral for six months from now that will not fly. So kind of you put them in a bind and force them to help you solve the problem.

Jenn: I do want to provide for folks tuning in, if there is an immediate sense of urgency around any of these situations for you or a loved one, the National Suicide Prevention Lifeline phone number is available 24/7 for free in the US.

You can call 800.273.8255, that is it spells out talk on a touch phone. [Note: Call 988 to reach this same hotline.] The crisis text line if you don’t want to speak to somebody is 741-741 from anywhere in the US, and that is run by SAMHSA, which is the government Substance Abuse and Mental Health Services Administration.

And lastly, The Trevor Lifeline is from The Trevor Project, so they provide LGBTQ+ suicide prevention phone services. You can either text Trevor text, you can text the word START, S T A R T to 678-678. Or you can call them at 1.866.488.7386.

Again, these are all available in the US, so if you are listening internationally, a quick internet search of Suicide Prevention Lifeline with your wherever you are living in the world, like the UK or something should come up with a little bit of information, but if there is an immediate need, stop listening now do what you need to.

Dr. Palmer I don’t want to derail the entire conversation, but I do want to ask you had talked about lately about situational depression. Can you provide some of the differences between situational and clinical depression? Is it something that like symptomatically is different or is it a whole range of things?

Chris: It’s a really important question and one that we could talk for hours or days on and about, and it’s actually one of the biggest it turns out that it’s actually one of the biggest controversies in the mental health field.

And, you know, some people in the mental health field think major depression is a separate entity far removed from normal human experience. And that they see it as a black and white thing, that it is an illness and that you can have normal mood, you can have normal anxiety, normal depression, but that’s not at all major depression.

Once you have the nine symptoms, you know, or five of the nine symptoms of major depression that puts you into the illness category and now you have something completely different. So I want to acknowledge that controversy up front, so what I’m going to say is controversial but I’m going to take a side.

And my stance is that I actually think it is a normal continuum. That, so you can have a young teenager, I’m just going to pick on teenagers right now. The young teenager in love, madly in love, fell in love, head over heels in love, they’ve been dating for two months, everything is going so well and then one of them breaks up with the other.

And what happens to that person that got their heart ripped out, torn apart, spit on, stumped on, what happens to that person? Probably 95 out of a hundred times, major depression, the symptoms of major depression.

Now whether it lasts the full two weeks or not is variable, but certainly within days, within minutes of getting this news, that person will begin to display most of the symptoms of major depression.

They will feel devastated, they will lose all interest and pleasure in life, nothing is enjoyable anymore because this person was my lifeline, this person was the love of my life and now I’m devastated.

They’re going to have trouble sleeping, their appetite is going to be affected, they’re going to have trouble concentrating, they might even be thinking about killing themselves. Romeo and Juliet, kind of romanticizes that, but and that is not an uncommon experience, and I just want to acknowledge that.

It’s not uncommon when you especially for the first or second time, when you get your heart ripped out and you really thought this person was the love of your life, this person was like sent from God or karma, or like this is your soulmate, this is the person you’re destined to be with.

And then they don’t want you anymore, it is devastating, and it can actually feel like my life isn’t worth living I want to be dead. And so those are all of the symptoms of major depression. Now, how do we help that person?

The big thing that I want to say is that person does in fact need help. They are devastated, that person needs help. They don’t need to be told just suck it up, deal with it.

They need like a good family or a friend somebody who is going to say I get it, I remember feeling the way you feel, we’ve got to get you through this. I love you, your life still has meaning even though this person doesn’t love you anymore.

Like, that person needs help, they might need professional help if they’re really suicidal, if they’re really trying to hurt themselves, they might need professional help. Even if it hasn’t been going on for two full weeks, even if it’s only going on for three days.

If they have made a serious suicide attempt, that person deserves professional mental health help. Even though, by DSM-5 criteria, they don’t meet criteria for major depression cause it hasn’t been two weeks yet. And so I would say the criteria are worthless in that situation.

Now do I think that that person is abnormal? No, I actually I’m kind of acknowledging no that I think that’s within the realm of normal to feel that devastated. Is it normal to try to kill yourself?

I don’t want to say that’s normal or healthy it’s certainly not, but it’s hard for me to say that that is somehow this distinct disorder when so many people experience that thought, that emotion, those drives, those the urge to end their suffering.

It’s hard for me to call that, that is clearly pathological whereas everything else they’re experiencing is “normal.” So where you draw the line is very difficult.

Again, safety is important, preserving human life is important, I don’t at all want anybody to interpret what I just said is that person doesn’t have a problem, that person doesn’t need help, they clearly need help.

But that is a clear cut example of a situation provoking all of the symptoms, all of the devastating symptoms of severe major depression. And so where do we draw the line? And this is one of the controversies in the field, cause a lot of people minimize mental illness for this reason.

They all say, well I’ve been depressed, I flunked a test once and I got so down I got so down for days or weeks. Or I didn’t get into the college that I really wanted to go to, oh my God I was devastated, I was just devastated.

It was like I really thought that that college was going to like open doors for me, and then when I didn’t get in I felt like I was a failure, I felt like I’d ruined my life, you know, blah, blah, blah. So I’ve been depressed but I got over it.

So everybody else who has depression just needs to do what I did and they’ll get over it and it’ll all be fine. Well, no it’s not so simple. And so the way that I kind of draw the line is I think that there are situations that can provoke symptoms of depression.

If they are manageable and they are not endangering a person’s safety, that person needs community as their treatment. They need friends, family, everybody needs to rally and support that person and help that person through that social psychological crisis.

As soon as a person’s safety is in danger, you should be thinking about professional help. The clear, and so that can be a continuum but on the other end of the continuum I have seen countless people over my career, out of the blue for no clear reason, no psychological or social reason certainly, they just develop all of those same symptoms of major depression for no good reason.

Out of the blue, they feel like life is becoming worthless, that they are worthless, that maybe they should just kill themselves. And if you ask them what happened, what changed? They can’t really articulate anything.

I don’t know, I don’t know why I feel this way but I feel it and so I’m going to do it, or I’m going to act on it. Or sometimes they recognize and acknowledge like, I don’t know, I don’t know why I am so miserable, why I have no energy, why I feel so horrible I don’t know.

I can see that it’s not right, I don’t have a good reason to feel this way yet I do feel this way and it’s ruining my life, it’s preventing me from doing so many things that I want to do. And at that point it’s clearly a disorder, there’s no good reason why it’s happening.

So in those cases, I would easily put it in the bucket of that’s a disorder, that is not a normal reaction to anything because nothing happened.

And so where in that continuum you draw the line between oh, this is normal and acceptable, this is not normal this is, I would say is highly controversial and it really depends on societal factors, and social factors, and what country you live I mean so many different things will determine whether we label that an illness or not.

But again, just because I’m saying some cases are not an illness does not mean I’m saying those people don’t need help they do need help.

Jenn: One of the things that you’ve mentioned a couple times throughout that response is the importance of community and like the concept of inclusivity around supporting people through either depressive times or a full about of clinical depression. I know it’s important to listen to people’s experiences, but especially if you personally can’t relate it’s hard.

So if someone’s experience with depression is difficult for us to listen to, or has shocking details in it but we want to be supportive, how do we become better listeners that have more neutral and validating affects than we might be coming off?

Chris: It’s a really important question. And I think the first thing I would want to say is that depression has this quality that is somewhat contagious. And I don’t want to say it’s contagious it’s not like the flu or the cold or COVID, you can’t catch it in the same way.

But for any of you who have lived with somebody with chronic unrelenting depression, I will just share with you I have, personal in my life I have lived with a person who has had that. It rubs off on you, it does, it affects you.

It’s hard to not get at least a little bit depressed or discouraged or worn down, and it can feel like it’s sucking the life out of you it really can. And so first and foremost if you are in a position to try to support somebody who has major depression especially let’s say the severe kind, it’s just important for you to understand that, that this can start to rub off on me.

And I just need to check in with myself every now and then, and I need to rally my own supports and my own kind of, you know, take care of myself skills. And so that can be, if you’re in this position I want you as the caretaker or the supporter to be reaching out to your community your friends, your family, your coworkers, you’ve got…

If you’re religiously involved, your people in your religious community, or a minister or rabbi or whatever. I want you reaching out to those people letting them know I’m trying to support my father, son, brother, or like whatever significant other with depression and it’s just, yeah I’m doing my best, but it’s wearing on me and it would be really good to have somebody to help.

It’s really important that you take breaks and do your own self-care, that you get away from that person and that you get away from that situation. And it’s not that I don’t mean that in a mean way, but it’s important that you separate and that you are in non-depressed environments with non-depressed people.

If the person you’re worried about is suicidal and you feel like you can’t do that, that person belongs in a hospital, not in your care. You are not a hospital, no single person can be a hospital onto themselves.

So if somebody is really that dangerously ill that you’re worried they’re going to kill themselves if you leave them alone for three hours on Friday evening, then that is a dangerous, bad situation, and you’re in way over your head in terms of what you should reasonably be expected to be able to do.

So I think with all of, acknowledging all of that, do what you can, and it’s really about encouraging the person to get help, encouraging the person to fight. You know, I think one of the easiest tools that I use that I find helpful in situations like that is to really kind of talk about the person as a person, and then talk about the depression as a separate entity.

This is an illness, this is something you have to battle, this is I get that it’s part of you, I get that it’s making you discouraged, or it makes you, it makes everything difficult to do, but we’ve got to fight it.

And I would say something like that we have to fight this, not you have to fight this, we have to fight this. And so what you’re doing is you’re letting the person know I’m in this with you, I’m in this battle with you like I love you, I care about you, you’re somebody that’s important to me, you’re important to me.

And so I’m in this battle with you, we need to fight this. And but also always acknowledging we need help, I don’t know how to help you, so let’s get professional help if it’s coming to that.

I think it’s okay to let the person know that you know, that it can take a toll if they really ask you I wouldn’t go out of your way to point it out, but if they really push you on why do you need to go out on Friday night without me?

Or why do you need to spend, I would let them know. You know what? It’s hard, being depressed is hard, you know that I know that too, it’s hard on me too.

And I’m in this for the long run with you and it’s a marathon but I have to take a water break right now, I have to get, it’s kind of like when you’re running a marathon, you got to stop every now and then for water breaks, you can’t keep running, if you keep running and you never take a water break you’re not going to finish the marathon.

So I kind of look at it that way it’s kind of like, I just need a break just tonight, or I just I need some help or we need some help, but do what you can.

Jenn: That was I, do you have do you advice for folks who might actually feel guilty about taking care of their own health?

I know one of the biggest things is like parents they view themselves as parents and caretakers first and foremost, and a lot of folks that are in their 40’s, 50’s, 60’s are now in a really difficult position where they are not only parents but might be grandparents and also taking care of their parents.

So it’s a really difficult place to be in, and I imagine that it’s even harder to try and extricate yourself to say, I just need to take 60 minutes for myself. How can we help reset that internal monologue of these people come first, I can do this later, I don’t need to be doing this because their needs are more important.

Chris: And that’s coming from, I want to make sure I understand the question. So that’s coming from the person with depression or that’s coming from the caretaker?

Jenn: The caretaker. So especially if I know like a personal anecdote for this would be that my mother took care of both of her parents, and when one of her parents passed away, the other one moved in with her and was very depressed.

And it was very hard for her to say, I need to take 90 minutes to be able to do something for myself because she felt guilty about it, sorry mom.

Chris: Yeah so well, yeah it’s not, so number one for mom it’s not just you, it’s a, join to tens and tens of millions of other people just like you. And I think that’s what I was kind of referring to when I said it’s a marathon not a sprint.

And when you’re running a marathon, you must stop running at least or at least slow down and take water breaks. If you need to use the restroom it might be just decent and good to stop the marathon, stop running and use an actual restroom as opposed to these ridiculously crazy competitive people who don’t do that.

You can imagine what they do instead. So and I really mean that, we’re all human, so the guilt can come from, I should be stronger, I should be more capable, I shouldn’t need a break.

Well I have some news for those people, guess what? You’re human and sorry to break the news to you, sorry that that’s really disturbing but you are a human being and you do have your own needs.

And this is a really difficult exhausting task, taking care of somebody with serious depression. And especially when you’re living with the person you’re not getting any breaks, and that depression is rubbing off on you.

First and foremost, it is critical that you not become depressed, that you not allow that depression to take over you and then you start to become hopeless. Because now we’re going to have two depressed people with nobody around to take care of either of them and that’s going to be a nightmare situation.

So it is so much more important for you to take care of yourself and do whatever it is that you need to do to achieve that.

And that sometimes you can still be at home, it can just be I’m going to go into the other room, I’m going to do a yoga session, or I’m going to do some meditation, or I’m going to listen to music, or I’m going to have a drink or whatever you’re going to do to care of yourself.

But you’re going to go in the other room and take care of yourself, you’re going to take a break. But again, I can’t overemphasize it’s actually important for you to get out of that environment.

That environment becomes in its worst case scenario, and I’m really speaking to the worst case scenario it’s not always this way, and so I don’t want you to think I’m just being overly dramatic, but I’m trying to speak to like the really awful cases.

And in really awful cases that home become suffocating it really does. As soon as the person crosses the threshold and enters the door, they feel the just the heaviness of that environment because the severely depressed person is here.

The shades are drawn, there are no lights on but that person is in the room, and they’re just sitting there in a dark room staring at a wall. And when that is someone you love it is hard to, it’s hard to see that, it’s hard to be with that.

And it can just, when you feel like you’ve been spending weeks or months or years talking to this person, trying to make things better, and it’s still not better, it really can be this horrible thing.

And people can have different reactions at that point when they get to that point, they can either again but it’s one of two, it’s either they start to get sucked into the depression themselves and feel like it’s hopeless.

Can’t tell you how many parents in particular I’ve talked to, I can’t be happy until my child is happy. If you can’t fix my child’s depression, I am suffering and I’m going to continue to suffer until my child’s depression gets fixed.

So you start getting sucked into the depression, or you get angry, snap out of it, stop being that way, I’m so sick of it, just get out of bed, just get off that sofa, just go out do something, take more meds, I don’t care what you do, but just stop, stop being this way I can’t stand it.

Neither of those is helpful, so what I’m saying is they’re both normal I’ve seen a lot of people in both situations. They’re getting depressed or they’re just enraged, frustrated, they’re burned out, they’re done.

Neither is helpful, I want you to somehow be somewhere in between those, where you’re balancing I can engage with this person, I can be with this person, I can support this person, yet I have to step away from it and take care of myself.

And everybody is different, how much self-care you need is going to be very different than how much self-care I need, or Jenn needs or anyone else needs, we’re all different. And we all come to the table with different vulnerabilities, different experiences, different positions in life.

So no comparison, no comparing yourself to well I know somebody who was able to do what I’m doing and she could do it a lot better, well good for her.

She’s not there taking care of your loved one, you’re the one taking care of your loved one and you’re the one who’s trying to take care of yourself and your loved one and make the best of a bad situation. And so, you know, do your best to try to avoid these two extremes.

Jenn: I do have a question for you based on the fact that you said, you know, everybody is different, what are your thoughts on having all family members going to the same mental health practice and either seeing the same provider or different providers?

Before you answer, I have a feeling that it’s kind of like shopping in a department store. You can all buy something in the same store but you’re not all going to buy the same pair of jeans necessarily. But you can correct me if I’m wrong cause you are the doctor here.

Chris: No I think for the most part that’s correct. You know, everybody going to the same clinic if that clinic has dozens or hundreds of providers who cares yes, everybody can go to the same clinic.

I mean we have a lot of families for instance who come to McLean Hospital and they see different providers on different days in different circumstances. Those providers may have nothing to do with each other, they may not even know each other, and so it’s really you’re just seeing your own provider.

In terms of everybody in a family seeing one provider for their own individual work is a rule of thumb. You know, there are some circumstances where that’s going to be required.

So if you live in a small town out in the middle of nowhere and there is one and only one mental health provider, or God forbid there’s one and only one medical practitioner say a family practice doc, and that’s it that’s all you got for the entire town.

Guess what? If you and more than one family member have mental health problems that you need professional help for, you’re all going to that person, probably. So there there’s no way around it.

So there are some circumstances where you’re going to be forced into everybody has to see the same provider. But if you live in a large city and you have access to many different providers, and again that’s a huge caveat.

If you have access to a lot of different providers and you can actually get different providers for the different people in a household, as a rule of thumb, it’s better to have your own provider.

A lot of mental health clinicians will point this out to families, and they’ll say, I really don’t necessarily want to be treating your immediate family members because it can become a conflict of interest, especially if there’s conflict in the home.

Even if the provider can somehow be super human or non-human and legitimately not take sides, the family members are going to think that that person is taking sides. And so it’s better for everybody to have their own clinician.

And you know, it can feel like you have someone on your side, everybody’s got someone on their side and that’s what this provider is.

Not that your family members aren’t also on your side, but when there’s conflict in the family and there’s a disagreement, it can be nice for everybody to still feel like they have somebody to go to to talk about that conflict, and feel like that person is still kind of on their side looking out for their best interests.

It doesn’t mean that the provider is going to tell that person you are right, but they’re there to support you and your needs, and if you were wrong, if you did do something wrong that was harmful to your family member, they’re there to help you understand that and point it out in a non-judgmental non-threatening way, so yeah.

Jenn: If a family member is struggling with major depression, but refuses to try medication and is also struggling to find a therapist, how do we best support them?

Chris: It’s a really good question. I think as I mentioned before one way to support them if you haven’t already done this, is to offer to help them get, offer to help try to find a therapist that they can work with.

Because again, finding a therapist is a daunting challenge, finding a psychiatrist is a daunting task right now. So if you have the capacity to try to help, I would try to help.

And it can be calling all of those different referral sources, networking in your own community, asking your friends, family, coworkers, other you know, faith community wherever, just letting people know.

Do you know of a good therapist? I know someone you don’t even have to out the person, you can just say, do you know of a good psychotherapist? I know somebody who really needs someone. And do you know anybody who might know anyone?

The reality is a lot people know people who know people, and so almost everybody knows someone who has a mental health condition. And so you can ask them, you know, who do you see? Do you like the person? Are they good?

And try to get referral sources and then just make lots and lots of phone calls, be prepared for lots and lots of rejection or lots of non-responses, that’s the most frustrating to most people is, well I called that therapist and they never called back and it’s two weeks later, should I keep holding out?

Maybe they’re on vacation or should I give up is two weeks enough time that they’re not going to call back? And that can be frustrating and challenging. And again when somebody is depressed it can be overwhelming and feel hopeless.

So the more of that leg work you can do the better. I would be less inclined to try to force them to take medication for instance. If somebody wants a specific treatment and it’s a reasonable treatment option, so psychotherapy for major depression is a reasonable treatment option.

I think it’s perfectly reasonable to try do your best to support their autonomy, because if you force them to take a medication guess what? They’re probably going to be more likely to have side effects to that medication.

They’re probably going to be more likely to find problems with it and you know whatever. Because they didn’t want it already they already told you that they don’t want it. Nobody wants to be forced to do something they really don’t want to do.

And then the other thing you can do to support them is again, just let them know you love them you care about them, how they are helpful, why they’re important to you, that can help rally and motivate people to stay in the game.

When people get really depressed even moderately depressed it’s pretty common for people to lose confidence and start to think that they are worthless.

They can start to convince themselves, I am a burden, I am worthless, I see that my loved one is getting depressed by being around me, and I’m just bringing them down, they would be, everybody would be better off if I wasn’t here.

So those are common thoughts with depression, and it’s important to just preemptively understand that, and let the person know you are important to me, I love you, I care about you, you’ve been a good friend whatever they are. Don’t tell them stuff that’s not true.

People with depression are actually really good at picking up lies, so don’t lie. Think of something that’s true and tell them that true something and just let them know that you want them to stay in the fight.

That this is a fight, it’s a fight for their health and you are in it with them, and you want to support them, hope that helps.

Jenn: Do you have any tips for parents that want to explain an extended family member’s major depression to a young child?

Chris: I think it depends on how young the child is honestly, cause different children are going to understand different things.

At its simplest, you know, with a young child or a child who doesn’t understand complex subjects it could just be as simple as you know let’s say it’s grandpa, grandpa is sick. Grandpa is really sick, he doesn’t feel good, he doesn’t have any energy, and we’re working with the doctors to try to get him feeling better.

His body and his brain aren’t working well right now, we just need to get them working better. And you can tell by looking at grandpa he’s sick.

And then you can encourage that kid to again rally grandpa I love you, grandpa you know, I can’t wait for you to feel better enough so that we can toss baseball around or so that you can come to my, you know, concert at school, or so that you can, you know, those kinds of things can be really motivating.

So get your child to help out in those simple ways. And what you’re really doing, I’m not encouraging you to get your child to be a mental health clinician that’s not what that’s about, what that’s about is family.

And emphasize into your child, family is important and we are in family together and we are with each other and we support each other even when you’re down and out, and that’s what we do.

So you’re modeling for your child and teaching your child how to do that. If it’s an older child I think you can start to get more sophisticated in what depression is, but it’s probably easiest for most young children to talk about depression as an illness, and really put it in that black and white bucket.

That this is an illness, this is a disorder, you know, so and so is sick, and we’re working with the doctors to try to help them feel better.

Jenn: When I want to talk a little bit about young adults, so teens that are 18, 19, basically are considered adults legally. If one of them has clinical depression and cuts or self-harms, how can they be helped or treated when they’re resistant to getting help?

Chris: So that is, it’s one of the biggest questions. Whenever I do mental health webinars or for the general public, it almost always comes up. Is how do we help someone who refuses help? And the real answer is there are no easy answers.

The tragic answer that I’m just going to put out on the table that is in fact the answer that some families end up with, tragic answer at least here in the United States, it is a free country and people have the freedom to be mentally ill and live their lives in that way.

Whether it’s depression, self-injury, alcoholism or schizophrenia and homeless on the street. People have that freedom, we do not have the right to round them up, hospitalize them, force them to get treatment.

The only circumstances that allow us to force treatment are when somebody’s life, when somebody’s safety is in danger, or they are endangering other people’s safety, or they are grossly unable to care for themselves.

But I want to point out, grossly unable to care for yourselves, yet we have an entire homeless population throughout the United States and throughout the world that somehow doesn’t meet the muster for unable to care for self.

So when we talk about this tension between freedom to be mentally ill versus even something like take care of yourself, the courts and the legal system and our kind of constitution have sided on the side of they have the right to be ill and we don’t have the right to force them.

So for some people that ends up being the answer they must accept and sadly. Now you don’t have to accept that right away, and I would strongly I’m a mental health professional so I’m biased, but I would strongly encourage you to not accept that right away.

And I would strongly encourage you to try to motivate the person to get help. And so that comes to this whole topic of the, you know, one model there are lots of models for how to do this.

You know people talk about interventions, people talk about all sorts of things, but probably one well studied model of how do you convince somebody to get help who doesn’t want help, is this concept called motivational interviewing.

And there’s a whole there are books written on it, there are websites on it, there are articles on it, so if you’re not familiar with that term I encourage you especially for the person who asked this question to Google, motivational interviewing and do some research on it and look up some of the tips.

The general concept of motivational interviewing it was first developed for working with people who have substance use disorders who don’t want help. How do you convince them that they need help and how do you convince them to get help?

And it’s really, it ends up being a somewhat non-confrontational process of engaging with people, looking for ways, looking for opportunities to highlight to them, or point out to them, or just increase their awareness of all of the ways that their illness is interfering with their life.

Is bringing them down, is slowing them down, is inhibiting good things from happening in their life because of this illness.

And trying to get them intrinsically motivated intrinsically upset that, yeah you’re right I want to have a job, yeah you’re right I want to have a boyfriend or I want to get married someday and have a family, but this depression and self-injury is getting in the way, and I’m never going to be able to do those things if I don’t get over this depression and self-injury.

So you’re looking for ways to motivate them you’re looking, and at the end of the day for a lot of people, it’s one little thing, it’s one thing that actually ends up being the big motivator.

I want to get married and have a family someday, I want to have a job someday, I want to move out of my parents’ house someday, I whatever it is, I want to travel someday. It doesn’t matter what it is. All that matters is that you’re trying to motivate them, and if you can find something that is motivating to them, then you roll with it.

And then you start to have discussions and conversation with them around gosh, I see you kind of giving into that depression and self-injury again, it’s a shame that you’re not working with somebody who might be able to help you, I wish I knew what to tell you, but I don’t, I don’t know how to treat that myself.

I would tell you if I knew what would work, but I don’t know what would work, but it just makes me sad as your parent because I see that you’re not, you may not get the things that you said you want out of life because of this.

And the thing that’s really frustrating to me is that I do think that there are professionals who might be able to help you with this. I do think there are professionals who might be able to make this better so that you can have the life that you want, so that you can get the things that you want.

And you’re my daughter I love you, I only want I’ve like, all along I’ve only wanted you to be happy and healthy, or even if you want that, even if you wanted her to get straight A’s before you can say, I can see I was wrong by focusing on grades, now all I want for you is happiness and health.

And it’s just frustrating knowing that you’re not getting help when maybe help is available.

Jenn: I want to try and end our conversation on a realistic but also positive note. I wanted to ask you, what are some realistic expectations for caregivers about depressed family members getting well?

Is there the possibility of them ever being “totally better?” Or should you really just expect some variations or degrees of improvement?

Chris: It’s a really important question. And you know, I think most mental health professionals today would say, hold out for remission.

We have lots and lots of treatments available, we have lots of pills, we have lots of psychotherapy, group therapies, we’ve got electroconvulsive therapy, TMS. There are surgical procedures that can be done on your brain, there are stimulators that can go into your brain, with all of those treatment options, hold out for complete full remission.

If you look at the statistics on what actually is happening around the world to people with treatment resistant depression let’s assume it’s treatment resistant, that they’ve already tried several treatments and they haven’t worked.

Cause if they haven’t tried any treatments, absolutely try a treatment because for some people do get really lucky and they get this full remission and they live happily ever after and it’s all good.

But assuming they’ve tried treatments and they’re not really working, they haven’t worked all the way, they are not alone I think number one letting them know you’re not alone. Even though they say this is treatment resistant depression, and even though some people suggest that with all those treatment options everybody else is getting all better.

No, everybody else is not getting all better unfortunately. That’s why depression is now the leading cause of disability, not just in the United States but on the planet. In the entire world, depression is the leading cause of disability, and it’s not that those people aren’t getting treatment they are getting treatment, the treatments aren’t working for them.

So that is just a difficult painful fact that we have to kind of struggle with as a mental health field. I will tell you this though, you know, my professional work looking at the effects of diet and exercise for instance on depression, leads me to have a lot more hope.

And it leads me to have a lot more hope because it is allowing us we as a field are actually much, much closer than most people realize to really understanding what causes depression. Even though a lot of different things can cause it, psychological problems, social problems, biological problems.

They’re all causing the exact same symptoms, and so they fit together somehow. And once we fully understand how they all fit together, we will actually be able to come up with more effective treatments and solutions.

And there is no doubt in my mind that diet and exercise are part of those novel treatments. The reason that’s so hopeful in my mind is number one, diet and exercise are available today. We don’t have to wait for a new drug to be developed and new patents to come out.

They are, I can’t say they’re free because sometimes people want to join a gym or sometimes people need to buy special foods. So I can’t necessarily say they’re free, but they are relatively inexpensive and they are relatively available to almost everyone on the planet.

Different dietary interventions can be done in all sorts of ways. And I really say dietary intervention, so I am not at all suggesting that if everybody eats a little more broccoli, their depression and their schizophrenia will go away, I am absolutely 100% against that kind of simplistic thinking, it’s not that.

But dietary interventions can change our biology, and change our physiology, change our neuro-transmitters in our brains, change hormones that affect our brain function, and change levels of inflammation in our brains, and can do all sorts of things.

That we know and have good reason to believe based on the best science that we have the cutting edge science, that wow, if you have a treatment that can rebalance neurotransmitters, correct hormonal imbalances and decrease brain inflammation, and change the gut microbiome in a positive way, that would be a really, really powerful treatment.

Well guess what that treatment is? It’s a dietary intervention. And so I am full of hope, and that hope leads me to hopefully what will be coming soon as a new day in the mental health field. Where we begin to expect and see much, much greater levels of complete remission of illness than we’re seeing right now.

Jenn: Dr. Palmer, I want to be cognizant of your time, so I’m going to bid you adieu first before I provide a list of resources that are free for folks to use virtually 24/7 if you are living in the US.

So Chris thank you so much for joining, and I hope that we can continue this conversation even sooner, so thank you again.

For folks who are tuning in who need resources immediately, first and foremost, the National Suicide Prevention Lifeline is available 24/7 across the United States. You can access it by calling 1.800.273.8255.

If you prefer texting, you can call or sorry you can text the crisis text line you can all you have to do is text 741-741, and you’ll be connected with a trained crisis counselor. If you are looking for LGBTQ assistance for folks under 25, The Trevor Lifeline is a crisis intervention and suicide prevention phone service, where you can either call 1.866.488.7386, or text the word START, S T A R T to 678-678.

The Trans Lifeline is for fighting the epidemic of trans suicide and improving overall life outcomes of trans people in the United States, you can call 877.565.8860 to be connected to someone.

Last but certainly not least, The Veterans Crisis Line is a free confidential resource available to anyone, even if you are not registered with the VA or enrolled in VA healthcare. You can call 1.800.273.8255 and press the number one, or just text 838-255.

And folks, I know we talked about a lot of heavy topics, but there are resources out there, you are never alone. So thank you so much for tuning in, this actually concludes our session, until next time, be nice to one another, but most importantly be nice to yourself. Thank you again and take care.

Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

- - -

The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

© 2022 McLean Hospital. All Rights Reserved.