Clinical depression, also known as major depressive disorder, is different from the layperson's term depression as it involves multiple symptoms, and it affects an individual's functioning. Clinical depression can certainly present as sadness, but it often affects an individual’s sleep and appetite. Individuals will find it difficult to perform their typical daily activities at home and at work. Clinical depression can take away your energy, your drive, and your ability to find enjoyment in life. Clinical depression is sustained over time for at least 2 weeks but in some cases, episodes can last several months. An individual may even get to the point of feeling desperate and hopeless, which can be associated with suicidal thoughts and behaviors.

Each year in the United States, it is estimated that a little over 8% of the adult population will experience clinical depression. Women are more commonly diagnosed. Depression will often look different in men versus women and with men tend to be less likely to seek treatment. For these reasons, men are oftentimes underdiagnosed and undertreated. Although the criterion for the diagnosis is the same, men more commonly present with irritability and anger. Men may find it more difficult to verbalize their feelings and will often be more socially isolative during depressive episodes. Women are more commonly diagnosed with depression and women are more likely to attempt suicide. However, men are much more likely to complete suicide because of the use of more lethal means such as firearms.

There is a clear distinction between major depressive disorder and bipolar disorder and an important one. Individuals with bipolar disorder will experience at least one episode of hypomania or mania in their life. Mania is a sustained period of elevated mood and/or irritability and an increase in goal-directed behavior. There are varying severities, but it is common for individuals to have a decreased need for sleep and an increase in energy. Often family members can see a change in the individual’s personality and behavior. It is common for individuals in a manic episode to engage in more erratic and impulsive behaviors. Individuals may talk faster and change the subject repeatedly. Mania can also present with psychosis which is to say that the individual can develop hallucinations and delusional thinking. Again, mania is a distinct episode and not the individual's typical baseline. This needs to be distinguished from emotional dysregulation in which an individual experiences mood fluctuations throughout the day which can be seen in borderline personality disorder or baseline hyperactivity seen in attention deficit hyperactivity disorder. These distinctions are important as the treatment of these conditions differ.

Clinical depression is caused by a combination of biological and environmental factors. In many cases, an individual will have a genetic predisposition which is to say that there is certain genetic material that is being passed along in their family that makes it more likely for them to develop clinical depression. There will then be environmental factors that can potentially precipitate the onset of the condition, and this can include stressors but even potentially substances which includes drugs and alcohol. Studies have suggested that marijuana can perpetuate depression and alcohol is a known brain depressant. Psychological factors will also play a role, and this involves an individual's expectations and their identity. The mind is a powerful thing and an individual that expects and identifies with a bad outcome will find just that. An individual's mindset can make a world of difference in their eventual outcome.

Let me start by saying that you have come to the right place. Here at Serenity Bay Health, we approach the treatment of clinical depression as a team effort. This team involves everyone in the building including the doctor, therapist, nurse, support staff and most importantly you and your supports. All of us will be working towards the same goal, to get better. This team will have the mindset that we will not give up and we will keep pushing forward. Your needs and preferences will be the highest priority every step of the way.

Studies show that a multimodal approach to treating clinical depression is the most effective. This is to say that the most effective strategy is one that attacks clinical depression at multiple different angles and involves the use of medication, psychotherapy, lifestyle modifications and even supplements/vitamins.

Antidepressant medications have been shown in studies to be effective in targeting the core symptoms of clinical depression. There are many antidepressant medications, and the list keeps growing. Choosing the right antidepressant medication needs to consider multiple factors which includes psychiatric comorbidities such as anxiety or ADHD, medical comorbidities such as obesity, hypertension or heart disease and most importantly your own preferences. Most commonly, SSRI (selective serotonin reuptake inhibitors) antidepressant medications such as Prozac, Zoloft or Lexapro are felt to be first line. These medications not only treat clinical depression, but they are also highly effective in helping to alleviate anxiety which is a common comorbidity. These medications are well-tolerated although there are certainly side effects that can occur. Side effects include nausea, weight gain and sexual dysfunction. There are different strategies that could be implemented to help alleviate side effects and some may need to change to a different antidepressant medication. This is something to discuss with your provider. There are also dual action antidepressant medications such as Effexor and Cymbalta which are less likely to cause weight gain and may also help with chronic physical pain which is common in those with clinical depression. These medications should be titrated more cautiously to minimize certain side effects such as nausea and a feeling of being jittery. These medications should also be tapered and discontinued slowly as they are more commonly associated with withdrawal symptoms. There are certainly other classes of antidepressant medications and even newer agents on the horizon, and these are things to discuss with your provider who will be more than willing to address any questions that you have.

In many cases, antidepressants will be found to be helpful but not necessarily adequate in achieving the goal. In the case of residual symptoms, your provider may talk with you about adding an agent to your antidepressant medication to boost the effectiveness or potentially target specific symptoms/comorbidities. There are times that a provider may consider the use of an antipsychotic medication such as Abilify or Vraylar which have been found by many to be effective for clinical depression. As always, one needs to balance the desire for improvement in one's mood with the potential side effects that can come with the addition of a medication. Many antipsychotic medications are associated with weight gain and other metabolic side effects and these medications can also affect a person's muscles and movement. It is common for individuals to feel restless after starting one of these medications. Any potential side effects and concerns should be discussed with your provider and the nursing staff will be available to field questions over the phone in between appointments.

Psychotherapy is talk therapy and oftentimes an individual will meet with their therapist weekly for about an hour. There are multiple different therapeutic modalities, but the most common and evidence-based treatment approach is that of cognitive behavioral therapy. This approach is based off the idea that our mood, thoughts and behaviors are all linked together. Many times, individuals are caught up in a downward spiral in which their depressed mood leads to negative thoughts and a more inactive and sedentary lifestyle which in turn results in a worsening of their mood. The idea is to reverse the spiral by targeting negative thoughts and promoting healthy behaviors. Through certain exercises, the therapist helps to promote more positive thinking and activity with the idea that the mood will follow. Therapy will require effort, but the benefits can be great. There are certainly other treatment modalities as mentioned above including interpersonal psychotherapy. You will work with your therapist to develop a treatment strategy tailored for you specifically.

As previously mentioned, certain lifestyle modifications and even the use of certain vitamins have been proven in studies to be effective in alleviating symptoms of clinical depression. There are many studies proving the effectiveness of exercise. Exercise was commonly defined as cardio for 45 minutes 3 days a week in which the individual achieves a heart rate that is 50% higher than their resting heart rate. There are even studies suggesting that exercise can be just as effective as medication in the case of mild to moderate symptoms. By adding exercise to the treatment plan, an individual will have a higher likelihood of achieving remission. Likewise, healthy eating and vitamin D supplementation have also been shown to be helpful for clinical depression. Lastly, cutting down on the use of substances such as marijuana and alcohol will certainly have a positive impact. These are things to discuss further with your provider.

Clinical depression has been associated with suicidal thoughts and suicidal behaviors and there may be times when an individual does not feel safe at home. Likewise, there may be times when family members have concerns about their loved one's safety. In this case, there are higher levels of care available for more intensive treatment and to help maintain safety. Options include IOP (intensive outpatient program), PHP (partial hospitalization program) and inpatient psychiatric treatment. Serenity Bay Health is developing both IOP and PHP, but adult PHP is also available through Mclaren Hospital in Bay City and MyMichigan Hospital in Midland. PHP is an outpatient program that is 7 to 8 hours a day 5 days a week. IOP is less intensive, and it may be 3 to 4 hours a day 2 to 3 days a week. Otherwise, both programs are similar and involve individual and group psychotherapy, which is typically the program's emphasis. Individuals will also meet with a prescriber, but the frequency varies depending upon the needs of the individual. Inpatient psychiatric treatment involves being admitted to a locked mental health unit emphasizing safety. Both Dr. Nicholas and Dr. Cox help care for individuals admitted to Mclaren Hospital's mental health unit in Bay City, but there are other mental health units in the area in Midland and Saginaw. The length of stay in the mental health unit is variable but the average length of stay is about 6 days. Inpatient treatment also involves individual and group therapy, and individuals will meet with a psychiatrist daily. These options are certainly something that can be discussed with your provider at Serenity Bay Health.

There is a certain percentage of individuals with clinical depression that are considered treatment resistant. A large study estimated that 31% of individuals with clinical depression will be treatment resistant but other studies have suggested an even higher percentage. An individual is treatment resistant if they have tried and failed 2 different antidepressant medications. In this case, your provider may recommend a more aggressive treatment strategy involving the use of Spravato. Spravato is a ketamine product that is delivered intranasally. This medication must be administered at Serenity Bay Health or another certified treatment center, and the individual will need to be monitored for 2 hours after each treatment and will require transportation home. Spravato has been proven to be highly effective in this population of treatment resistant individuals and it is very well-tolerated with no long-term side effects. This is certainly something to discuss further with your provider.

There are other treatment strategies that involve brain stimulation, and this includes electroconvulsive therapy and transcranial magnetic stimulation. Electroconvulsive therapy is still considered one of the most effective treatments of clinical depression, particularly those that experience catatonia (slowed movement and speech) and psychosis (hallucinations/delusions). However, this treatment approach can result in cognitive impairment, and many will require maintenance treatments to maintain the improvement. Transcranial magnetic stimulation is better tolerated but less effective than electroconvulsive therapy. These strategies are not currently offered at Serenity Bay Health but can be discussed with your provider and a referral may be provided.

It is an exciting time in psychiatry as there are many new treatment options that are in development and studies are underway. One such treatment option on the horizon is the use of psychedelic agents such as psilocybin for use in major depressive disorder. In fact, the FDA (Food and Drug Administration) has granted breakthrough therapy designation to psilocybin and one specific agent, CYB003 (Cybin), has just completed phase 2 trials showing that just 2 doses of this medication resulted in a remission rate of 75% and this was sustained over time. This has now been moved on to phase 3 trials that are expected to begin soon. This is a very promising treatment option and should provide hope for those struggling with clinical depression.

Here at Serenity Bay Health, you are not a number or just another patient but a key member of the team. The members of the team trust one another and can rely on one another. Treatment plans are tailored to the individual, guided by individual needs and preferences. We will all be open and honest with one another and if we have questions we will ask them. We will develop the plan and we will put in the work. This is going to be an active process that requires effort, and we will do everything in our power to move forward towards the goal. Families will play a vital role in the support of their family members and in accountability. Family can of course listen and love but even helping with transportation and encouraging compliance with treatment are oftentimes necessary to succeed in achieving the goal. This will be a journey that will not be perfect, nor will it be easy, but it will be worth it in the end. This journey, like the mission of Serenity Bay Health, is an action and a purpose that involves togetherness and hope. Whatever obstacles along the way, this team will continue moving forward and we will not give up.