Carlo Carandang, MD, FAPA, a leading expert in anxiety and depression, has opened a private practice in psychiatry in Seattle. To book an appointment in Dr. Carandang’s Seattle office, please visit his practice website here.
Treatment resistant depression (TRD), also known as treatment refractory depression, is defined as failure to respond to 1st and 2nd line treatments. The first question to consider is if the diagnosis of major depressive disorder is correct. It may be a misdiagnosis, and may be the reason for the lack of response to treatment. For example, it could be a medical problem like hypothyroidism, electrolyte abnormalities, and anemia (B12 or iron deficiency), just to name a few. The depressive symptoms could also be caused by a medication or a substance of abuse. Once the medical problems are ruled out, then the psychiatric diagnosis may be incorrect. For example, if the diagnosis is adjustment disorder with depressed mood, then psychotropic medication may not alleviate the depressive symptoms…typically psychotherapy and addressing the stressor is helpful.
If indeed you have the right diagnosis of major depressive disorder, then the psychiatrist needs to consider if adequate dose and duration were tried with the previous treatments, and if not, to optimize the dose and duration. If symptoms continue after the optimization, then the psychiatrist may consider switching to a different class of antidepressant, such as switching from a selective serotonin reuptake inhibitor (ie sertraline- Zoloft) to a norepinephrine serotonin reuptake inhibitor (ie venlafaxine- Effexor). If this does not work, then the psychiatrist may consider augmenting the antidepressant with another medication such as lithium, thyroid hormone, or lamotrigine (Lamictal). Lamotrigine is a promising medication for TRD, and can even be used as monotherapy for TRD. Lamotrigine is advantageous for TRD in that it has a tolerable side effect profile when compared to other psychotropics for TRD like lithium. Lamotrigine just has to be dosed slowly to prevent severe rash from occurring.
Finally, electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS) are last resort treatments for TRD. The most important aspect of TRD treatment is finding a psychiatrist who specializes in TRD and performs research in TRD. You can find these TRD-specialized psychiatrists at most university hospitals, as the university hospitals have all the infrastructure and expertise necessary to carry out the complex TRD treatments like ECT and VNS. rTMS is becoming more available in psychiatrists’ offices.
If you are considering a career as a psychiatrist, these are important and exciting times for the profession, as it tries to figure out the neurobiological underpinnings of mental illness. Currently, clinical psychiatry does not have objective, biological tests to help confirm mental illness. Rather, mental illness is diagnosed based on history and clinical presentation. However, psychiatry is fast becoming a specialty of medicine based on the brain. The mind, and the various problems and illnesses that are from disorders of the mind, can basically be explained at a molecular level, with neurons communicating with each other via synapses, and these synapses connect to one another via neurotransmitters. These neurotransmitters are the chemicals which carry out the message between neurons, and the receptors of these neurotransmitters are the targets of the psychiatric medications prescribed for mental illness…this is the so-called “chemical imbalance” theory of mental illness. But mental illness is much more complex than a chemical imbalance. In the brain on a macro level, mental processes have specific circuitry, which connect different parts of the brain, and this circuitry is comprised of the neurons which conduct the message between brain areas. Functional neuroimaging is already revealing preliminary evidence that mental illness is associated with disruptions of these brain circuits, and that treatment can normalize these circuits. In addition to neuroimaging research, genetics research is on the verge of finding the constellation of genes responsible for the transmission of mental illness in families. In the next few years, psychiatry should have objective, biological tests to help diagnose mental illness, and cures may be possible.
Given the multitudes of research in the neurosciences to find the biological underpinnings of mental illness, it is a great time to join the ranks of psychiatry. As a student interested in psychiatry, it would be advantageous for you to have an undergraduate degree in a science field, given the neuroscience emphasis in psychiatry over the past two decades. The following knowledge and skill set are important for the modern biological psychiatrist: organic chemistry, neuroscience, statistics, clinical trials, neuroimaging, genetics, epidemiology, psychopharmacology, psychology, evidence-based psychotherapy, biopsychosocial model, business management (for managing your medical practice), and managing clinical teams.
In high school, if you already know you want to be a psychiatrist, you should take chemistry, physics, biology, Latin, a second language course (to communicate with patients in your region who speak a different language), English literature, home economics (you need to know basic activities of daily living), athletics (physical activity to model good health), debate team, student leadership positions, and pre-calculus. If possible and if you have the time in high school, take all the AP (advance placement) courses you can find, like AP English, AP Chemistry, AP Calculus, AP History, so you can get college credit and get into a top undergraduate premed program. In high school, I would also recommend that you volunteer for hospitals and medical clinics, as it shows dedication to the medical profession. I would also recommend that you get paid work, as it demonstrates maturity, experience, knowledge, skill, and organization that an employer is willing to compensate.
For college, you should attend a top tier private or public university. People recognize brands, so go to a brand university that everyone knows. And if you have to pick between an Ivy League university and a top state university (of which you are a resident of that state, as in-state residents get the lower tuition costs), pick the top state university, as it is cheaper, and it is easier to be at the top of the class at a state school. Remember, medical schools are looking at those from the top of their class, so if you are at the bottom of the class at Harvard, then you will most likely not be accepted to medical school. It is easier to be a big fish in a little pond. As an example, in Texas, the top private university is Rice University, and the top public university is the University of Texas at Austin. I chose UT-Austin, graduated at the top of my class, and was granted admission to a state medical school, the University of Texas Medical Branch School of Medicine at Galveston. I’m sorry Texas A&M and Baylor, but in Texas, Rice and UT-Austin are tops for undergraduate universities (and for graduate school in UT-Austin’s case).
You have to go by the numbers and follow them…this is not about allegiance to a particular school…it is about getting into medical school, which is highly competitive. As an example, when you look at the 8 allopathic (MD) medical schools in Texas, the majority of the medical school enrolees have undergraduate degrees from Rice or UT-Austin. So the formula to get into the medical school of your state of residence is to try to gain admission to the top private school or the top public school in your state for your undergraduate degree…in Texas it is Rice and UT-Austin; in California, it is Stanford and UCLA; in Nebraska, it is Creighton University and University of Nebraska; in Massachusetts, it is Harvard and University of Massachusetts; in Illinois, it is University of Chicago (Northwestern is probably tied) and University of Illinois.
Once you gain acceptance to your top-tier state private university or top-tier state public university for your undergraduate degree, you can pick any major, but the majority of students who get accepted into medical school have a science degree. This is a matter of convenience for the premed student, as the requirements for applying to medical school are full of science courses. Certainly, you can focus on a non-science major, but you will have to work harder to fulfill all the science courses for pre-med, which will not be included within your non-science degree. From the time you enroll at university, start looking at MCAT test preparation, as a high MCAT score is also needed for acceptance to medical school.
So you made it to medical school…congratulations. In these tough economic times, the competition is fiercer, as the unemployed will join the ranks of returning to graduate schools or professional schools. During the basic science years, focus on neuroscience, behavioral sciences, brain and central nervous system (CNS) dissection in anatomy, pharmacology, genetics, epidemiology, statistics, research methodology, medical ethics and clinical trials. During the clinical clerkship years, focus on family medicine, internal medicine, psychiatry, neurology, neurosurgery, neuroradiology, neuropsychiatry, and psychiatric research.
For psychiatry residency, pick one that is going to give you the best chance of becoming a competent, modern, biological psychiatrist. The future of psychiatry is what I have been discussing above, so you need a program that does research into the neurobiology of mental illness. This type of program will best position you to develop the necessary knowledge and skills to be a modern biological psychiatrist. Although psychiatrists need to learn and utilize psychotherapy, it is not something that is utilized in daily psychiatric practice as a primary modality, as psychiatrists are just too expensive to relegate them to just talk therapy. Avoid psychiatric residencies that focus on psychotherapy only, as you will not learn the biological approach to psychiatry at those programs.
As you see, the modern biological psychiatrist wields diverse knowledge and skill set. The modern psychiatrist also requires an analytical mind to synthesize the various subjective data and produce a formulation for each patient. Hopefully, in the coming years, psychiatrists will be able to utilize objective biological tests to aid with diagnosis and treatment planning. This is an exciting time to join psychiatry, given it is at the brink of finding the cause (and cure) of mental illness.
Depressive disorders are characterized by low moods, feeling blue, or having apathy on exposure to a painful situation such as loss, disappointment, relationship problems, financial difficulties, and/or trauma. Bereavement, also known as grief, is differentiated from depression, in that bereavement is a normal reaction to the loss of a loved one and short-lived, whereas depression is more chronic, impacts your functioning, and lingers even with time passing. In addition to bereavement, sadness is a normal response to painful situations, where sadness is short-lived, while depression lingers and impacts your functioning. Both bereavement and sadness can turn into depression if the depressive symptoms linger past 2 weeks and you have multiple symptoms which impact your functioning.
Depression can occur when you are presented with a painful situation, and you start thinking negatively about the situation and about yourself. In response to the painful situation, you may think the situation is hopeless, you may think you are worthless, you may have no hope for the future, and/or you may think nothing will change. This negative thinking may then lead to feeling depressed. Depression may also be associated with other feelings, like shame, guilt, anger, or anxiety. Your self-esteem may also be low, you may not find pleasure in things, you may have difficulty concentrating, and you may have no hope for the future, to the point where you may also have thoughts of suicide. In addition to feeling low moods, you may have physical sensations of depression, including fatigue, exhaustion, lethargy, sleep disturbance, appetite changes, body pains, and headaches. Because you are depressed from the negative thinking and have fatigue, sleep problems, pain and eating problems, you tend to do less and less. Soon, you start to isolate and stop doing the things that used to bring you pleasure. You may also stop going to work, stay in bed, and ignore your relationships. These isolating behaviors in turn make you feel more depressed, getting you caught up in a vicious cycle of depression.
Depression, also called major depressive disorder, occurs when the depressive symptoms cause impairment of your functioning in relationships and work/school. The major depressive disorders include major depressive disorder, dysthymic disorder, and bipolar depression. Other depressive disorders include substance induced mood disorder, mood disorder due to a general medical condition, adjustment disorder with depression, minor depressive disorder, recurrent brief depressive disorder, and premenstrual dysphoric disorder. The major disorders are associated with the following:
- Major depressive disorder- low moods or anhedonia with other symptoms of depression for at least 2 weeks
- Dysthymic disorder- chronic depression for at least 2 years
- Bipolar depression- depression that occurs in bipolar disorder
Depression treatment involves psychotherapy, with cognitive behavioral therapy (CBT) having the most evidence for efficacy. CBT works on the premise that events or situations do not directly cause the depression; rather, the thoughts we have or the meaning we give the events causes the depression. CBT works by identifying the maladaptive thoughts, working on more adaptive thoughts, and suppressing/distancing oneself from the maladaptive thinking. In addition, CBT addresses the avoidant and isolative behaviors which serve to sustain the depression over the long term. Other forms of psychotherapy include depth or insight oriented psychotherapy, which addresses the causes and the proximal determinants of the depression. If psychotherapy is not effective, or if the depressive symptoms are severe, then pharmacotherapy with depression medications can be considered after a psychiatric assessment. Other treatments for depression include self-help treatments, natural supplements, and alternative interventions for depression like exercise, meditation, and diet. If you are experiencing severe depressive symptoms or have suicidal thoughts, please contact your doctor immediately.
Anxiety disorders are characterized by extreme fear, nervousness, or worry on exposure to a feared stimulus, which can be an object, person, or situation. Fear is differentiated from anxiety, in that fear is a reaction to a current stimulus, whereas anxiety is fear of some future stimulus or anticipation of one. Anxiety becomes a problem when one becomes fearful, nervous, or worried out of proportion to the feared stimulus, or becomes nervous or worried about some future stimulus or anticipated event.
Fear is a normal response, and is a necessary component of survival. When presented with danger in the environment, a physiological reaction is triggered where adrenaline is released into the bloodstream. Adrenaline is a fear-response hormone which causes several physical changes in the body, including increased heart rate, increased rate of breathing, and dilated pupils. In addition, there is shunting of the blood flow from the digestive system and the skin to the skeletal muscles, which can be felt as having the “butterflies” in the stomach or having numbness and tingling sensations of the extremities. These physical changes allow the person to prepare to fight the danger, or to run from it, the so-called “fight-or-flight” response. The increased heart rate and breathing rate allows the blood to supply more oxygen to the skeletal muscles needed to fight or run, and the blood shunting to the skeletal muscles further aids this process. The dilated pupils allows for improved vision to assess the danger, and the brain becomes more alert and hypervigilant for danger, allowing one to scan their environment in order to deal with the external danger. However, this fear response goes awry when one starts to anticipate danger, or starts to have thoughts about events which overestimate the danger and underestimate one’s ability to cope with the danger. In this situation, the fear response is heightened by one’s thoughts about the event or future event, where the overestimation of danger and underestimating of one’s coping leads to anxiety. Unfortunately, the body perceives fear and anxiety the same way, where the adrenaline response is triggered with either fear or anxiety. So when one has anxiety, the fight-or-flight response is activated, and serves no purpose as the danger is more in one’s head and the way they think or give meaning to the situation.
Anxiety becomes an anxiety disorder when the anxiety symptoms cause impairment of functioning in relationships and work/school, and the person has significant distress and is unable to control the anxiety. The major anxiety disorders include generalized anxiety disorder, specific phobia, social phobia, panic disorder, post traumatic stress disorder, and obsessive compulsive disorder. Other anxiety disorders include substance induced anxiety disorder, anxiety due to a general medical condition, acute stress disorder, adjustment disorder with anxiety, separation anxiety disorder, and selective mutism. Each disorder is associated with a specific core anxiety symptom:
- Generalized anxiety disorder- generalized worries
- Specific phobia- fear of an object or situation (ie fear of heights)
- Social phobia- fear of social scrutiny (ie stage fright)
- Panic disorder- panic attacks
- Post traumatic stress disorder- flashbacks and nightmares of trauma
- Obsessive compulsive disorder- intrusive thoughts and ritualistic behaviors
Anxiety treatment involves psychotherapy, with cognitive behavioral therapy (CBT) having the most evidence for efficacy. CBT works on the premise that events or situations do not directly cause the anxiety; rather, the thoughts we have or the meaning we give the events causes the anxiety. CBT works by identifying the maladaptive thoughts, working on more adaptive thoughts, and suppressing/distancing oneself from the maladaptive thinking. In addition, CBT addresses the avoidant behaviors which serve to sustain the anxiety over the long term; this can be a difficult task, as the avoidant behaviors serve to relieve anxiety in the short term. Other forms of psychotherapy include depth or insight oriented psychotherapy, which addresses the causes and the proximal determinants of the anxiety. If psychotherapy is not effective, or if the anxiety symptoms are severe, then pharmacotherapy with anxiety medications can be considered after a psychiatric assessment. Other treatments for anxiety include self-help treatments, natural supplements, and alternative interventions for anxiety like exercise, meditation, and relaxation. Please see AnxietyBoss.com for more information and help on anxiety.