This video is part of a 3-part series on “Current Landscapes of Major Depressive Disorder Therapeutics.”
View part 1 here: https://www.clinicaltopicsdepression.com/video/current-landscape-major-depressive-disorder-therapeutics-part-1
View part 3 here: https://www.clinicaltopicsdepression.com/video/current-landscape-major-depressive-disorder-therapeutics-part-3
Saundra Jain: So let me ask you guys this.
Andrew Penn: Yeah.
Saundra Jain:
Craig, you mentioned this. I heard you say the word psychotherapy. And before, I just want to go back to guidelines. They're not guiding us very well. But with mild to moderate depression, the recommendation is psychotherapy, CBT, interpersonal psychotherapy, which I love hearing that. That's music to my ears. But I also wonder how many of us in clinical practice are following those guidelines? And if we're not, is it because our patients don't want to do that because it's not a quick fix? I mean psychotherapy is more ongoing than what it may in their mind. They feel like a medicine is a quick fix. Not always the case, but that's the belief. So, is it more the patient sort of resistance to psychotherapy? Is it lack of access to a trained CBT clinician? Because we all know there's not enough of us to go around anyway. But when you look at specific trained specialty, like manualized focused psychotherapies, like CBT, sometimes finding someone who's very skilled in that can be a challenge, particularly in rural areas. So, I don’t know. Are we following that guideline or not really?
Craig Chepke:
No, I mean the answer of what is it is kind of all of the above. I mean, you mentioned a lot of the challenges and hurdles that our patients are facing, and we as clinicians are facing too.
Andrew Penn: Yeah.
Craig Chepke:
And I feel like my patients are more likely to be able to access CBD than CBT, because there are too few therapists that are available that are trained in that.
Saundra Jain: True.
Andrew Penn: Yeah. You're not wrong. Yeah.
Craig Chepke: I'm just saying.
Andrew Penn: Yeah. And the evidence is stronger for CBT.
Craig Chepke:
I think so. I agree. I agree as well. But to be able to find someone who's trained in that, and are they full, or are they taking new patients, and are they financially accessible? Are they geographically accessible? I mean, treatments like psychotherapy can't be limited to just people who are affluent enough to live in an urban or suburban area. I mean, in rural places that you might not have a therapist for maybe hundreds of miles. And I mean telemedicine has maybe chipped away a little at that. But still, I think in some ways it's almost revealed some of the greater disparity that really, there are not enough therapists even if you do throw it open to telemedicine. There’s just a lot of challenges that we face. And patients also may have tried therapy once and they didn’t feel better, or God forbid, they feel worse because they did some of the emotional work they needed to do. "And it made me worse. I'm never going back. It didn't work for me. I tried it." I always tell patients that finding the right therapist is like dating. Sometimes you got to kiss a lot of frogs before you meet your Prince Charming. And so, you got to keep trying. You got to find the person that you click with.
Saundra Jain:
Well, I wonder if we could liken that to taking a medication and a patient has a really bad side effect. And what do they always tell us?
Craig Chepke: That's a great idea.
Sandra Jain:
I mean even as a psychotherapist, they will say, "I'm never doing that again."
Andrew Penn: Yeah, medication or medication ill.
Saundra Jain: Thanks a lot for referring me for that because I'm never doing it.
Andrew Penn: That's right.
Saundra Jain: Not just that medicine, any medicine.
Andrew Penn: All medicines, yeah.
Saundra Jain:
And it's like, oh that's really... That was an unintended consequence. Right?
Andrew Penn:
But I think that the issue is a systems issue. Because I live in San Francisco, I can't swing a cat without hitting a therapist; but I can't find them for my patients because they're all busy. They're all full. And trying to find somebody that takes insurance in my urban area is really difficult, let alone somebody who's trained in manualized evidence-based therapy.
Saundra Jain: That’s right.
Andrew Penn:
And also some of the systems that we work in; I’ve worked for Kaiser, I’ve worked for the VA, and often at the very beginning of treatment, when the person first calls for that first appointment, one of the first questions is going to be, “Are you interested in medication or are you interested in therapy?”
Craig Chepke: Oh.
Andrew Penn:
So, we’re already beginning to silo people into two different groups depending on their personal preference. And so, somebody who elects for medication might not have the opportunity to avail themselves for CBT for their mild to moderate depression. And they're going to get funneled right to medication if that's the person they see. Because when all you have is a hammer, everything looks like a nail, right? Which is probably why we prescribers need to be reasonably competent therapists too.
Craig Chepke: Oh yeah.
Andrew Penn:
We can't just be writing prescriptions all day. We need to think about that and sometimes be able to say, "Actually I don't think medication's appropriate here. I'd really like to see you do X, Y and Z. Maybe see this therapist colleague of mine before we come back to medication and consider that. It's not hard no, but I don't think it's the right time for this." So being able to have that level of discernment as a clinician is critical.
Craig Chepke : Yeah. The best surgeon is one that knows when not to cut.
Andrew Penn: Agreed. Yeah.
Saundra Jain: Good point.
Andrew Penn: Yeah.
Saundra Jain:
I think it's also this opportunity, like you were saying Andrew, about being siloed and how sometimes that conversation, that it's either or instead of and.
Andrew Penn: Right.
Saundra Jain:
Whether it be that the prescriber also does psychotherapy, or as a psychotherapist I see myself as a conduit between the patient and well, just say prescribers; whatever the specialty is, because I have more time with my patients, see them more frequently, and it's an opportunity to ask about medicines, adherence. “Are you forgetting? Are you keeping track? Have you had any side effects?” And this is the most common answer, "Yeah, you know it really gave me a really bad headache or I couldn't sleep." "Have you contacted your clinician?" "No, I just have an appointment in a couple of weeks. I'm just going to wait." “Well, okay, let’s not. How about we don’t do that? And how about we just take a minute that you call now, just leave a message because you don’t have to wait.” And so, there's this opportunity to really practice what I believe is true collaborative care. I mean, for goodness sakes, we've been talking about collaborative care for decades, just like we've been talking about reduction of stigma for decades. But this seems like one of those baby steps. This is a way where we can all work together really in the best benefits of our patients.
Craig Chepke:
So, I'm fortunate enough to be married to a psychotherapist myself, and I often say that I might put people on medications; but it's my wife who keeps people on medications for exactly what you just said.
Saundra Jain: I like that.
Craig Chepke:
They’re more likely to tell her about side effects that they’re having, or things that are good or bad about it. And they don't think about telling me, or they'll wait too long to tell me. And she does exactly the same thing that you do. And even if we think that a person does really, they need pharmacotherapy, we should be enlisting psychotherapists as well because they can help with the adherence, and help with the education, and keeping people on that pharmacotherapy that could, in some cases, be the more important aspect. But I mean, therapy's always important for everybody really. But even just from a pragmatic perspective, being in therapy will keep people in treatment, and that's the most important thing.
Andrew Penn:
Yeah. And I think part of it starts with how the person thinks about their symptoms. So, if the person sees their symptoms of depression as a biological phenomenon, they're going to call somebody who can prescribe medications. Because what they're thinking is that's going to tweak their biology, versus if they think it's something to do with their story, or their life history, or their circumstances—they're going to go to a psychotherapist. Well, guess what? So, we know that psychotherapy changes the brain. So, it's not as if that's not changing the soma. Right? And we know that medications make it so people can change their behaviors, and so they're not so partitioned. But I think a lot of it, where you end up begins with how you think about your own experience of illness. And whether that's a story or it's biology; whichever end it's weighted on, is going to probably determine who you call for that first appointment.
Craig Chepke:
And just like when I ask people about past medication trials. “What side effects did you have?” I want to know exactly what happened.
Andrew Penn: Yeah.
Craig Chepke:
Similarly, thinking about psychotherapy in that regard, because if someone is so profoundly, neurovegetatively, cognitively depressed, and they go to therapy and try it-
Andrew Penn: How are they going to do it?
Craig Chepke: It's never going to work.
Andrew Penn: Exactly.
Craig Chepke:
So sometimes people are too sick to participate in therapy. And then they get a negative perspective that is biased and inaccurate as to the potential for therapy to help them.
Andrew Penn: Absolutely.
Craig Chepke:
So sometimes I'll tell people off the bat that, "Look, you really are going to need therapy, but right now you're too depressed for therapy. You couldn't even get the motivation to get up, take a shower, get dressed, brush your teeth, get out the door, and drive to a therapist, let alone do the type of emotional cognitive work you'd need to do to get better. But after this medication starts to hopefully kick in and you're starting to get some of that back, you're not going to get to where you want to go unless you get into therapy. And we'll decide together when that's going to be. But just want to let you know up front, that's going to be part of the plan in my opinion."
Andrew Penn:
Yeah. And I so appreciate you drilling down into those details when you're taking that history. Because if somebody says, "Oh, I tried therapy and it didn't work," and you don't have that other piece that says oh, so neurovegetative when you try to go to therapy that all these homework exercises, and even just the time and energy it takes to sit in a chair for 50 minutes was totally inaccessible to that person in that moment. So, then you can present another option of, "Why don't we try this after you've had a course of medication? Maybe get a little bit of symptom relief. Have the energy and the wherewithal to be able to go and avail yourself with therapy, and we'll try it again?"
Rather than saying, "Tried therapy, failed."
Saundra Jain:
Well, and this may be a great sort of tie back to where we first started talking about, where we were laughing and joking a bit about, the guidelines don't really guide us very well. But if you look at that guideline that for mild to moderate depression, psychotherapy is appropriate.
Craig Chepke: Yeah. Good call.
Saundra Jain:
It's exactly what you're both illustrating by clinical examples that I'm just too tired. I mean, where I see it is patients who come into therapy first who are so anxious, so on the verge of a panic attack just sitting in the office. It's like, "Okay, you can't do what I can offer you. You can't even hold space for that."
Andrew Penn: Right.
Saundra Jain:
So then saying, "Hey, this really seems like an appropriate referral to someone for a... Let's just do a medication evaluation. And then once stable and the anxiety kind of settles a bit, then you and I can start working together."
Saundra Jain:
So maybe this is a really great example where the guidelines are guiding us well.
Craig Chepke: And we're just not listening.
Saundra Jain: Yeah, so maybe.