hi, i'm kyle kittleson with med circle joined today by clinical psychologist, dr romini, dr romney. Wonderful, to see you thanks for being here. Thank you so much for having me now when most people, or at least when i think of mental health, i think of depression, and we hear that term used all over the place. Uh severe depression, though, is much different than what we would consider. Just a standard mild depressive state feeling severely depressed can be debilitating, but it's not always caused by major depressive disorder, which is what many people assume from your perspective. As a psychologist, can the signs of severe depression get misdiagnosed or lumped together under major depressive disorder it they can. I mean, i think, that's a tricky bit to remember when we get to the more severe levels of depression, depression's on a continuum
Okay, so at the milder levels of depression, you might see somebody whose energy is a little lower than usual. They might be sort of feeling having negative thoughts about themselves there. They definitely can see a change in their mood. They are, you know, feeling something's wrong. Something'S not right and in those milder levels of depression, you're much more likely potentially to see either, if not a misdiagnosis, a co-occurring diagnosis that depressive symptomatology may fit better with, for example, grief or an adjustment disorder or even a personality disorder. It might be co-located with anxiety when we start creeping up to the much more severe levels of depression.
What we see is much more of what we call the vegetative symptoms of depression and by vegetative we mean things like real impacts on appetite, sleep concentration and people who have very severe depression. You might see really major stealth care deficits that they actually literally stop eating. Properly, they might just shove like three, whatever it was close to them in their mouth and and go back to sleep.
People who are severely depressed might be what we call very hypersomnic. They might sleep all the time like 18 19 hours a day, their sleep cycles may be completely distorted. Their windows blackened very little contact with the world and then again, augmented by these terrible feelings of worthlessness. Just a slowing down an absolute apathy. They really don't get anything done, they won't bathe, they probably don't change their clothes, they won't brush their teeth, they cannot function. They will not be working, they likely don't have any human relationships at this severe level of depression. You'Re, almost getting into the point of danger Right the person who is so not taking care of themselves. They may very well not be taking their medications either for depression or anything else, any other health conditions they have they because they're not eating adequately. If they have some other health condition, I don't know like diabetes. They could be making that worse um. If there's anyone else in their purview, honestly, even children or pets, Those may not be getting taken care of properly, but it's just literally a person who cannot function when we have that severe a depressive presentation odds are that that is a major depressive episode.
Now it's conceivable, something else may have been happening in that other per then that person's life, for example, they may have endured a major loss right. So maybe there was the loss of and it's horrific like an entire family or something like that, and you might see that kind of massively major grief reaction, but we would still be addressing the severe depressive symptomatology. The research is actually very interesting. The effectiveness of antidepressants at the mild to moderate range of depression researchers have actually been there's two camps. There there's some groups that believe that any effect we're seeing in milder depression is more of a placebo effect. Pharma people often think that they actually do work in mild to moderate depression, but when we get to the moderate and severe levels of depression, medications matter - and so that's one thing to remember - is that some of those mild depressions might be more sort of reactive to Circumstance those severe depressions may be more of what we consider the genetic depressions, the more biological depressions
They may not even be reactive medications and at the most severe cases, if the person is non-responsive to any medication, they might even trying to try to use treatments like ect or even some kinds of brain stimulation stuff like tms or that kind of thing. So it is much more debilitating and i think it is depression at that point. I'M always fascinated as somebody living with depression on why i feel depressed. Certainly sometimes i can uh point out and go it's because of this, and i know that and when i uh can point that out, i actually feel really good because i go there, it is there's the cause, there's the reason, but in my life what was that? Yes, it's exactly right when you can say like this is what happened that makes more sense. People can almost derive more meaning out of like what is happening, which makes a difference yes, but many times in my life and really three times in my life. It was i mean i was bedridden, i mean i did not do anything and i couldn't pinpoint why - and you mentioned, that that could be a more genetic depression.
Can you speak to like what what causes that so there's some people that actually believe that the onset of a first depressive episode and that can be very reactive, something happens in a person's world uh they have a breakup, they um, they lose their job. Something goes wrong and they have a depressive episode as a reaction to that there's. Actually one hypothesis out there, the kindling hypothesis that says that that first oppressive episode almost sets up a kind of a a sort of a a reset of neurotransmitters
That makes a person more vulnerable to ongoing depressive episodes. That would happen without a trigger. As though that first episode kind of booted the brain into sort of depressions and option kind of a place, then the neurotransmitters came along for the ride, which is why those first episodes of depression are so important to prevent. And why things like stress management and all of those issues become so important, especially in adolescence, because that going into early adulthood is when we often see that first depressive episode. All of that said is that there's many people out there who experience major depressive disorder, which is recurrent major depressive episodes right. They have an episode, there's a break. They have an episode, there's a break that some of the episodes they can sense.
Yeah There was some sort of trigger, but, as time goes on, they'll see that they do kind of come spontaneously. People are trained if they're in and they should be in therapy and getting psychiatric support to start identifying sort of the downswing that you can start feeling. The difference the change in the prevailing winds, because at that point it becomes really important to work with a psychiatrist and a therapist about maybe upping the number of sessions, maybe changing the level of medication. So you can be almost responsive to the recurrent major depression, and so i do think you can see a mixed bag. I would this is this. Is me shooting from the hip i'll be frank with you, because i i think that i mean i don't have the sort of the chapter and verse of the science in front of me. But there's one belief that, if a person's having more of what we consider like a biological depression - genetic depression, it's really all it's not reactive. You tend to see more of the kind of low energy high apathy. Sleep appetite shifts almost like more of those vegetative symptoms that seem to speak to more of a neural origin to the depression rather than the cognitive symptoms of depression.
I'M no good nothing's ever going to go my way. The world is a hostile place. Life is always bad. Why should i even try, and so it has a different flair now, with most people depression both of those things come together. They have both the vegetative and the cognitive, but i think the milder levels. You may see a little of low energy, A little low energy, but not as much as you see at the higher moderate to severe levels, which may speak to sort of different kinds of depressive symptomatology. In terms of the way the central nervous system is working interesting. I can hide my mild depression great. I show up to work, i smile, i shake hands, i'm pleasant i'll, attend your dinner and then i'll go home and sulk and then go to bed and repeat, okay. I cannot hide my severe depression, it's impossible! It'S an impossibility! So are there any people out there who could be hiding their severe depression, be severely depressed and their loved ones wouldn't know? I would find it incredibly incredibly unlikely kyle unless the loved ones didn't live with them.
I think if you live with someone severely depressed, there's no way you would miss it right if somebody didn't live with someone, and especially if they already had a pattern with them, where they didn't see them that often right they don't uh, they don't call that much That might go, i suppose unnoticed it would. But if you have eyes on the person, it's an it's unmistakable, i mean you see it they're, literally their posture changes. They'Re they're, like they're slumped they their their faces, will often look quite unhealthy. They might look very unkempt. The complete loss of energy that accompanies severe depression means that in many cases a person doesn't even engage in the self-care, so a person will notice like wow. They don't look that good. Now a person might think they're physically ill. Somebody looking at them saying. I wonder if they're sick, you know they have some sort of medical illness and may not identify it as depression, but i would say other than in the rarest of cases, and it does happen.
Kyle is that some people might be able to mask their severe depression through things like routine. Their routine is so set that they can roll from point a to point b to point c to point d and get things done out, all the while they feel like they're, dying inside kind of thing. And so it's possible, and i think that more that there's routine they're familiar with that routine and the less that there are caring people who are watching them, because those people would likely know the more that a person might be able to get away with it tonight. During our live panel, we're going to talk to dr romney and our other med circle, doctors and we're going to focus more on supporter strategies and treatment options for severe depression.
If you're interested in attending that live panel, use the links below or go to, medcircle.com for more information are the signs and symptoms of severe depression different in a child compared to an adult? Yes, and so one of the challenges is with children and depression. Adults tend to be a little bit more consistent in how they present emotionally right. You know, we know, i know what to expect.
For example, i've known you for a long time. I know what to expect, so i could probably sense if there's a dip or a raise because you're, consistent kids aren't kids are kind of all over the map. You know they'll they'll get exaggeratedly sad at something and exaggeratedly agitated. That'S kids, they're sort of like this big bucket of unregulated moods as they're supposed to be. That makes diagnosing mood disorders in children very challenging because we don't have what we call a good baseline now in a very young child.
It gets like when we're looking at real pediatric depression, five, six, seven years of age. That'S actually not my area of expertise, but we can have. There can be patterns of depression in children that age and you what we always. I always tell people with children. What you're looking for is change, so you know what this child's habits are in terms of when they wake up how they eat, how they play, how they might interact with peers or siblings when they go to sleep, if there are significant changes in that, that cannot Be explained by an environmental condition, you're aware of, for example, you've just moved, or you know something like that happened - that that change should definitely be a red flag that pops up for a parent that something in the realm is likely happening and at that point consult With a pediatrician or someone, some other child's child psychologist, who can help sort of unpack that children aren't always great at identifying moods like, whereas an adult might say? Oh, i think i'm really depressed child's not going to have that vocabulary so you're, looking more at their rhythms.
Now, as we march up more into puberty and adolescence, the game changes a bit. What looks like depression feels a little bit easier to identify, but teenagers aren't exactly the most. You know talkative expressive group, especially when they're depressed, and we know under the condition the conditions of the pandemic rates of depression have been skyrocketing in adolescence and so and and what we do also see during puberty is hormonal changes and depression is in part a hormonal. There are hormonal responses, especially in girls when they have the onset of their uh menstrual cycle. So there are all these little entry points we see, but we look for changes and shifts and patterns now, just because your child's pattern has shifted or changed doesn't necessarily mean it's depression, but something's happening it could be bullying at school. It could be that they're enduring some other form of trauma or abuse.
It could be depression, it could be anxiety, it could be any number of things. That'S why it's important to get evaluated, because when there are changes in kids, that's really the ringer. Now are there any mental health conditions or disorders that could be confused for severe depression? You know if we think about what could be potentially confused with severe depression. It could be, You know, one thing could be um honestly, we'd always start always start with the biology First and work your way down. So if a person has severe depression, it is absolutely critical that they see a health care provider to get a full lab panel and a full physical exam, because it may very well be that this is a biological origin, especially if It represents a very rapid shift. In mood like it's, not it's, they were one way and then they quickly became another way and they don't have a history of depression that could even speak to other other ideologies like a person having had a stroke or some other Central nervous system process. Metabolic processes are associated with depression,
All of that needs to be worked up. So if i'm seeing a new severely depressed patient, we need labs. We need them to go, see a physician once that gets ruled out. The next place We always want to go is substance use. Are they engaged in substance? Use of a form, especially, Are they using central nervous system depressants? Those would be things like alcohol and things like that or are they coming down off of stimulants like? Are they is it? Is it related to that so we'd want to make sure we want to understand what their substance use profile has been recently and over their lifetime to see if that may be playing a role?
The next step i'd want to assess, is trauma. Have they recently experienced any kind of a traumatic event, or has there been an activation of an earlier traumatic event in their life and because, as we know, when we look at a post-traumatic stress presentation, while depression in and of itself, isn't a classical part of that Presentation, you might see someone having other symptomatology, like withdrawal avoidance, you know just sort of almost a paralyzed sense in the face of that trauma or a new trauma or an activation of an old one. That could bring that up. Then i'd want to look at grief. Have they just recently endured a major loss or losses? It may be not to the loss of a person, but it could have been loss of a spouse or a long-term relationship. The loss of a parent um, multiple family members,
A lot of families are dealing with multiple losses in grief right now, um. It could also be the loss of a business, a career, a home. I mean any any number of financial losses that culminate in real physical losses like you, no longer have your family home. Those things could be associated with a severe depression. I want to clear the decks of all of that first, okay, then we would start looking at other co-occurring mental health conditions simultaneously be aware of other major mental illnesses. This client may be living with. Do they have a psychotic disorder like schizophrenia or schizoaffective disorder mood, symptoms and mood presentations, including depression, can be a part of that presentation. You'D also want to look at something like bipolar disorder. Does the person have interspersed with their periods of mania, also severe depressions? You can definitely see that the treatment approach there is going to be quite different than it would be with somebody who has just straight up recurrent major depressive disorder.
People sometimes who have severe anxiety disorders will have depressive symptoms that accompany that. But then, in this case the depression may be a separate symptomatology from that you see significant depressive symptomatology and other mental health issues like like eating disorders, but you know i'm always going to come back to this place, which is the personality disorders, the co-occurrence of other Mental health conditions with personality disorders is something we know very well, and depression is actually one that co-occurs with a lot of personality disorders. The kind of chaos and dysregulation of the personality disorder may then kind of throw you off the path and you may have to be dealing with both of those sets of issues. So, as you can see, this thing called severe depression. You got to know a lot of stuff about the person before you can really land on it, but here's the bottom line, kyle. If a person is severely depressed, we have to
Obviously, we want to make sure it's not medical substance related and all of that, once we clear the decks of that. If a person severely depressed that becomes our clinical central focus, we want to alleviate that depressive symptomatology if it's severe, because otherwise they're not functioning and that's usually done with medication. You know they put medications on the person it takes a minute, but when a person's severely depressed, it's almost impossible for them to engage in therapy they're just sitting there they're almost not able to talk and engage
They feel like it's what's the point, so you almost need the uplift, the energetic uplift that comes from their medication to actually engage them in therapy really really well said. Thank you for all that, dr romney uh. We could talk about this topic for much longer and we will talk more about it tonight during our live panel. Med circle members enjoy in-depth video series from doctors just like dr romini, and we have an award-winning series that won the share care award a few years ago, which is basically the emmys for um for health content, and i will leave our viewers with an inside look Into that series and i'll see many of you tonight, dr romini, thanks for being here, i'm kyle kittleson, remember whatever you're going through
You got this and here's an inside look into debunking depression. What would you want Someone who suffers from depression to get out of this series do something about it. It is absolutely very treatable. You may not feel like it. You might feel hopeless right now. Trust me that is a symptom of depression. What you're thinking it may not be reality, and often it's not if you're feeling, helpless and hopeless. That is your depression. Do not listen to it. If it tells you, your life is not worth living you're. Nobody, your the world would be a better place without you. Nobody needs you do not buy into those voices in your head that are telling you that you're nobody and that you're nothing and that it's never going to get , better