Share ThisIn our Ask a Doc series, we sit down with physicians and other clinical experts, including those at Allegheny Health Network (AHN), for a chat on an important health topic. In this post, we discuss clinical depression with Dr. P.V. Nickell, a psychiatrist with AHN.
Depression affects 21 million American adults and is a leading cause of disability worldwide. Despite how commonly depression occurs, the stigma associated with receiving treatment for it persists: Up to 30% of people with depression never receive any treatment.
To learn more about depression, and specifically about identifying and treating Major Depressive Disorder (or clinical depression), I sat down with P.V. Nickell, MD, a psychiatrist with Allegheny Health Network, and the past system chair for the Department of Psychiatry.
Emily Beatty: For someone not familiar with different types of depression, what does Major Depressive Disorder typically look like?
Dr. P.V. Nickell: Major Depressive Disorder means that symptoms have continued for at least two weeks — and generally much longer — and negatively affect the way a person thinks, acts, and behaves. While symptoms can take many forms, Major Depressive Disorder most commonly affects an individual’s sleep or appetite. It can also impact one’s mood, producing lost interest in hobbies and activities, decreased energy, difficulty concentrating and making decisions, inappropriate feelings of guilt or worthlessness, a sense of helplessness and hopelessness, and in its most serious manifestation, suicidal thoughts.
Emily Beatty: If someone thinks they might be suffering from depression, what should they do?
Dr. P.V. Nickell: The sooner an individual seeks treatment for Major Depressive Disorder, the better. People with depression may find that their ability to complete the functions of daily living is impaired. This impairment can become so severe that they are no longer able to care for themselves or for others. Additionally, someone with Major Depressive Disorder is at a higher risk of self-harm or suicide. So early diagnosis and treatment really are critical.
Emily Beatty: How do you identify and diagnose this condition?
Dr. P.V. Nickell: The first step would be an assessment by a psychiatrist, other mental health professional, or a primary care physician. That would include reviewing your medical history and determining whether your symptoms are likely due to a mental health condition, or to a medical problem. More than 100 medical issues can masquerade as mental health conditions or contribute to them, which can complicate initial diagnosis and treatment decisions. For example, symptoms that appear to be depression could also be the result of an underactive thyroid, diabetes, Lyme disease, lupus or a sleep disorder. So we want to make sure we have the right diagnosis, and if it’s Major Depressive Disorder, then we discuss available treatment options.
Emily Beatty: Can you give us an overview of treatment options available for someone with depression?
Dr. P.V. Nickell: Sure, there are several effective, evidence-based treatments available. These include different types of psychotherapy, or talk therapy, as well as somatic treatments, most commonly medication. Often, it is most effective to combine psychotherapy with medication.
At least four common forms of psychotherapy have been studied — the same way we study medication — and proven to be more effective than placebo: cognitive behavioral therapy (CBT), interpersonal therapy (IPT), mindfulness-based cognitive therapy, and acceptance and commitment therapy.
As far as medicines, there are several antidepressants we can prescribe. There's no “best” antidepressant — the challenge is to find out what works best for each individual. That can be a trial-and-error process, but if we're careful and persistent, we can usually get good benefits with tolerable, if any, side effects. Beyond the commonly prescribed antidepressants, nasally administered ketamine has also shown promise, including in cases where other treatments haven’t helped.
Other somatic treatments include use of artificial sunlight, transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT).Emily Beatty: With treatment, can a person be completely cured?
Dr. P.V. Nickell: Typically, once a patient is feeling better, the challenge for the psychiatrist is to educate them on what they need to do to stay better. The available medications are not curative the way penicillin cures pneumonia; they treat the condition and the symptoms. It’s important to emphasize that feeling better isn't a signal to stop taking the medication.
Most people will cycle through an episode of depression over time. If somebody is experiencing depression for the first time, we wait until we believe that has happened, and then we taper them off the medication. That can be a year-long process or more.
We take a different approach for patients with recurrent depression. After three episodes of depression, for example, we typically shift the focus from treating the episode and tapering off the medication to treating the episode and then preventing depression from coming back. In other words, once someone is better, they may need to stay on medication to keep from having another cycle of depression.
Emily Beatty: How have rates of depression changed over the last few years?
Dr. P.V. Nickell: Depression rates are on the rise. In 2015, 6.6% of people aged 12 and older in the U.S. reported having experienced an episode of depression in the previous year. In 2020, that number rose to 9.2% of Americans aged 12 and older, with adolescents and young adults experiencing it more commonly than older adults. In fact, depression rates have been trending upward for even longer.
Emily Beatty: Setting aside the impact of the pandemic, what do you think is causing those rates to rise?
Dr. P.V. Nickell: Some likely contributing factors include sedentary lifestyles, overeating, and social isolation. On the positive side, over the past few years, most providers have enhanced screening processes for behavioral health needs, thus capturing more accurate data and identifying more at-risk individuals earlier than we did in the past. From my perspective, we are also making progress in reducing the stigma associated with mental health, so more people are reporting symptoms and seeking help.
Emily Beatty: A few years ago, you wrote an article for Highmark Health Digital Magazine about men and depression. Can you talk about the differences in how depression impacts women and men?
Dr. P.V. Nickell: Women tend to experience depression more often than men — depression increased in women from 9.7% to 11.8% between 2015 and 2019, and from 4.7% to 6.4% in men. However, it’s important to note that while women experience depression more frequently than men, men are less likely to seek help for depression and are more likely to die by suicide.
Men and women often present different depression symptoms. While men may complain less about feeling sad, they may be more irritable and try to cover up their depression by working more. They are also prone to drink more to suppress the symptoms, bottling up their emotions rather than talking about them. Men also may show a loss in pleasure from the things they used to enjoy, and often don’t want to recognize or admit that they feel depressed. If left untreated, the consequences can be dire.
Emily Beatty: Society puts a lot of pressure on men to embody the quintessential idea of manhood — tough, self-reliant, confident, and strong. Because of this, do you find that men are more reluctant to seek help and it’s a spouse or loved one that steps in?
Dr. P.V. Nickell: No one is immune to depression, and it’s important to note that mental illness does not make you any less of a person. But yes, in my experience, a man's spouse or significant other is often the one to call and set up the first visit. In many cases, the partner comes in for the first appointment — to be supportive or to make sure he comes to the office.
It is often very helpful to have the partner there because people always see us differently than we see ourselves. You can't say that one view is more accurate than the other, but they're different, valuable, and important pieces of information. Likewise, having a strong support system and people who want you to succeed is vital to ensuring that someone suffering from depression gets the help they need and that they stick with treatment.
Emily Beatty: You said earlier that you think we’re making progress in breaking the stigma associated with depression and mental health support in general. You also talked about the impact of celebrities opening up about mental health struggles in an article you wrote earlier this year for the Pittsburgh Post-Gazette. Can you talk more about where we are in the battle against stigma?
Dr. P.V. Nickell: Behavioral health experts, public health agencies, organizations like AHN, and others are all investing time and money to normalize talking about mental health issues and seeking support. I do think those efforts are paying off and we’re starting to see attitudes toward mental illness improve.
At the same time, something like clinical depression is not an issue everyone is familiar with or understands. It can make a big difference in terms of awareness and reducing stigma when a public figure shares their experiences. When a high-profile person like U.S. Senator John Fetterman openly talks about seeking inpatient treatment for depression after his stroke, people listen.
Emily Beatty: For those reading this article who may be struggling with depression or a mental health condition, what advice do you have for them?
Dr. P.V. Nickell: You are not alone. Mental illness can happen to anybody — it does not discriminate based on income or access to therapeutic resources.
Depression is complicated — the causes can be a mix of biology, genetic vulnerability, stress, trauma, drug use, chronic illness, and behavioral disorders. That is not your fault, and there is hope for you to feel better — but you must be willing to do something about it. There’s no “one-size-fits-all” treatment for depression, but with persistence and patience, most people will see significant improvements in their symptoms.
Emily Beatty: If someone has a friend or family member who may be struggling with depression, how should they approach discussing their concern with them?
Dr. P.V. Nickell: Starting the conversation about depression can be a challenging but beneficial and necessary first step. Consider starting with, "I'm concerned about you and let me tell you why I'm concerned. Maybe you can talk with me about whether I need to be concerned or not." And then just lay out what you've observed, and end with, "I'm concerned you might have clinical depression and might need some help getting through it." The National Alliance on Mental Illness has additional resources for family members supporting loved ones with a mental health condition.
If you or someone you know is in immediate distress or is thinking about hurting themselves, call the National Suicide Prevention Lifeline toll-free at 1-800-273-TALK (8255). You also can text the Crisis Text Line (HELLO to 741741) or use the Lifeline Chat on the National Suicide Prevention Lifeline website.
Dr. P.V. Nickell served as Allegheny Health Network's System Chair for the Department of Psychiatry from 2006 through 2021. He is Program Director for the Department of Psychiatry's Electroconvulsive Therapy (ECT) Services. He treats adults with major depression, bipolar disorder, schizoaffective disorder, catatonia, panic disorder, post-traumatic stress disorder, obsessive compulsive disorder, and social and generalized anxiety disorders. He has special clinical interests in treatment resistant mood disorders, catatonia, and co-existing psychiatric and medical illness.
Dr. Nickell is experienced in psychopharmacology and providing electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). He is a Life Fellow, American Psychiatric Association, and has been named to the Best Doctors in America, Woodward and White, every year since 1996, and named to Pittsburgh’s Top Doctors annually since 2011.
Highmark Health and its subsidiaries and affiliates comprise a national blended health organization that employs more than 42,000 people and serves millions of Americans across the country.
Entire contents © Highmark Health. All Rights Reserved.
Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.
Need to find info about providers, prescriptions, coverage, claims, ID cards, or health spending or savings accounts? If so, your Highmark member site is the place to go. (It’s separate from this blog.)