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Amid COVID-19, Dr. Rakesh Jain Shares Learnings From 33 Years of Treating MDD

July 01, 2020

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In this video, Psych Congress Steering Committee member and psychiatrist Rakesh Jain, MD, MPH, discusses reflections he has had during the COVID-19 pandemic about his 33 years of treating major depressive disorder. Dr. Jain is Clinical Professor, Department of Psychiatry, Texas Tech University School of Medicine, Austin.

Read the transcript:

Hello, everybody. I hope you are all doing well, even during these rather difficult days of this pandemic.

One thing about this pandemic is it's given me either times of being extremely busy with work, seeing patients using telepsychiatry, or after work, long stretches of time where I am really just with myself and my wife. It gives you time to think.

This is my 33rd year in psychiatry, and I've been going down memory lane a little bit. I have been thinking, over the last 33 years, what have I learned about major depression?

I wanted to share with you some of the top things I believe I have learned over the last three‑plus decades of taking care of patients who are afflicted with this disorder. Would you like to talk about that? Let's do it.

Perhaps the first thing I have learned in the last several decades about major depressive disorder is what a formidable enemy it is. It really is. It is common. It impairs every aspect of human life.

It sometimes is very difficult to treat, and sometimes eats away at the very core of who we are as human beings. The first lesson has been, for me, respect your enemy. Major depressive disorder is formidable.

Perhaps the second thing I have learned about major depression is that it can present in so many different ways. People can have primarily emotional symptoms. I've also seen patients whose primary presentation was physical symptoms. We also see patients with cognitive symptoms.

All three of them—physical, emotional, and cognitive—seem to create in most individuals a terrible mixture of symptoms that lead to huge impairment.

Here's another critical lesson life and time has taught me as I've treated patients with major depression, that being perhaps I was too simplistic in my approaches earlier on in my career when I was only offering patients either psychotherapy or pharmacotherapy, and that was essentially it. I no longer do that.

Now, with most patients, I'll offer a combination approach of psychotherapy combined with pharmacotherapy combined with wellness interventions, and perhaps even if it's appropriate and the patient so desires to talk about it, spirituality and religious practices.

Individualization is crucial, but it is also important to remember that individualization should not be an excuse not to offer them a whole array of potential options that could really benefit their life, things such as physical exercise, mindfulness, sleep hygiene, all are crucial as add‑on approaches to helping our patients fully flourish.

The last three decades have taught me another important lesson, that I really should know my pharmacotherapy well, in depth. Not just the basics, but in depth. I do need to know the pharmacodynamics of my medications and the pharmacokinetics of my medications.

I need to know how my antidepressants really work. I also need to know about their metabolism, their half‑life, their drug‑drug interactions, all of that. Not because I want to be an academic geek, but because it matters.

As a psychopharmacologist, it is my job to match the best interventions I have with the individual patient's needs. That is a very crucial learning for me over the last 30 years.

Something else I have learned over the last three decades or so has been to fully appreciate the importance of side effects. Side effects are not just a nuisance and a problem for our patients. They, of course, are, but can they can be real threats to adherence. They can diminish the quality of a patient's life, so I must respect side effects and do my very best to manage them. There are 3 side effects in particular that have really been an issue.

Weight gain. That has obviously occurred with several of my patients, and sometimes I have added to that burden with my pharmacotherapy, so I have to be very careful, and choose the right options for them.

The same is true regarding sexual dysfunction. Sexual dysfunction often comes with major depression, of course. I don't want to add to the burden. If anything, I want to help. Therefore, choosing my pharmacotherapy well has become of greater importance with the passage of time.

The same is true with cognitive side effects. I have seen—perhaps you have, too—that sometimes our interventions actually worsen our patients’ cognitive functioning. We've all had patients report, "My concentration's worse. My focus is worse. I'm having trouble with word finding. What is going on with me?"

Sometimes the problem is ongoing depression, but sometimes the problem is our pharmacotherapy, so a deep appreciation for side effects and finding ways to minimize them, hopefully eliminate them, is a crucial step for me to take. That has been an important deep learning for me.

Only in the last decade or so have I fully appreciated the cognitive aspects of major depression. I thought it was primarily emotional the first decade of my practice. The second decade, I appreciated it can be emotional and physical.

Then, in the third decade of my professional life have I learned to appreciate it really is all three. Cognitive symptoms can be hugely impairing, and they often are hidden. If I don't ask, they don't often tell.

They can range all the way from attentional difficulties—concentration, executive function—and they can impair and pervade every aspect of human functioning. Your work, obviously, your school, understandably, but also your home life, also your self‑esteem.

That's been the other great learning. If you want to understand depression and treat depression, treat every aspect of it, be it emotional, physical, or cognitive.

Finally, as we end our trip down memory lane, I remain cautiously optimistic. I must tell you that I'm very worried about the state of my patients and our society's mental health with this COVID pandemic. I don't think we have yet seen the worst of it.

I do think often mental health often takes a very large hit with the passage of time, and perhaps even more so when the crisis has receded. I'm expecting for all of us to face far more challenges with major depression through the passage of time. That part, I'm very worried about.

The cautious optimism comes from having watched how psychiatry has risen to the occasion. All of you, all of us in this profession have stiffened our resolve to fight mental health challenges, to confront depression wherever we see it.

We're using the very best tools. We're bringing our A‑game to the table. We're bringing not just our knowledge, but our passion to help our patients who suffer from major depressive disorder.

Thanks very much for going down memory lane with me. It's been a good experience to have this conversation with you. Here's wishing you and your patients the very best. Take care.

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