Your Checkup: What You Wish Your Doctor Explained
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Your Checkup: What You Wish Your Doctor Explained
The Depression Treatment Triangle: Medications, Therapy, and Behavioral Activation
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Depression requires a comprehensive treatment approach addressing biological, psychological, and social dimensions for true healing. We explore the three essential components of effective depression management: medication, therapy, and behavioral activation.
• Depression categorized as mild, moderate, or severe, with treatment options varying accordingly
• PHQ-9 questionnaire serves as both diagnostic tool and progress tracker
• SSRIs (like Lexapro, Prozac, and Zoloft) serve as first-line medications with fewer side effects
• Antidepressants typically require six weeks at therapeutic dose to determine effectiveness
• Psychotherapy, especially cognitive behavioral therapy, proven equally effective as medication
• Combined medication and therapy approach provides superior outcomes to either alone
• Psychology Today website offers accessible therapist-finding tool
• Exercise (30-60 minutes, 3x weekly) prescribed as essential treatment component
• Behavioral activation through resuming enjoyable activities crucial for recovery
• Recovery is possible with comprehensive treatment even when motivation is low
Visit psychologytoday.com to find therapists in your area based on specialty, insurance coverage, session format, and more.
Production and Content: Edward Delesky, MD & Nicole Aruffo, RN
Artwork: Olivia Pawlowski
Hi, welcome to Your Checkup. We are the patient education podcast, where we bring conversations from the doctor's office to your ears. On this podcast, we try to bring medicine closer to its patients. I'm Ed Delesky, a family medicine resident in the Philadelphia area.
Nicole Aruffo, RN:And I'm Nicole Aruffo. I'm a nurse.
Ed Delesky, MD:And we are so excited you were able to join us here again today. We just noticed that it was the first time in a long time that we haven't had eggs. Not because of the whole like high cost of living of eggs, but we just didn't.
Nicole Aruffo, RN:Well, we like didn't really eat breakfast.
Ed Delesky, MD:No, no, we didn't.
Nicole Aruffo, RN:We woke up I had a piece of toast and went for a run, and then you went to the gym and then it was like late morning and then we kind of just like ate lunch.
Ed Delesky, MD:We did. We just went right for it. Um, the fat rigatoni did happen later in the week. It was a surprise, a midweek dinner. I was elated. I came home and there it was. I was so happy. And last week we got sandwiches because that was what my dear nikki requested, and so, so, so it was. I mean, we're not going to we can't dive into all of our shows that we're watching because we want to respect that maybe not everyone is all caught up, but we are very pleased and all of it has been very entertaining so far. Would you agree?
Nicole Aruffo, RN:I would agree.
Ed Delesky, MD:And where are you heading tonight?
Nicole Aruffo, RN:Tonight I'm heading to dinner.
Ed Delesky, MD:We're going to laser wolf and I'm so excited yeah I'll report back on how it was notably, I am not joining, which is totally fine. You know you gotta. You know, spread your wings, I will. Chauffeur but going with my other boyfriend all right, you and your girlfriends are gonna have a great time. Great time At least that's what you're telling me, and so I can't wait to hear about it. I've never been, so you'll have to come back and give us a review.
Nicole Aruffo, RN:Hot off the press. I think it's going to be great, and then I think we'll have to go together.
Ed Delesky, MD:Well, yeah, I can't wait. That'll be great. Do you have any other thoughts about anything that came up this week?
Nicole Aruffo, RN:Hmm, that came up this week. Hmm, I don't think so. It's a pretty standard week.
Ed Delesky, MD:It was a pretty standard week. Well, by the time anyone is listening to this, it will be daylight savings again and we will have sprung forward. Every year, people are like, oh, we're getting rid of this. You hate when I talk about this for some reason. I'm excited that it's going to be lighter out later, but I've definitely become accustomed to waking up earlier. Yes, I know that it will eventually get back together and it will be easy again, but it's just. You know, it's change and tomorrow is technically the shortest day of the year, as we're recording this on Saturday.
Nicole Aruffo, RN:And for like yawning okay. And for like probably the first solid two weeks at least after daylight savings time. Eddie will just randomly be like wow, it's six o'clock, but really it's five o'clock yeah I do like to not like change.
Ed Delesky, MD:Immediately change the the clocks in the house, just to like.
Nicole Aruffo, RN:We're like whoa, we're waking up at six, but really it's like seven.
Ed Delesky, MD:It's fascinating. Ok, it's just like people together make a decision and say we are going to move the clocks. And I understand why. I had a long conversation over text. I talked to my dad about it and like I understand why. Now children a long conversation over text. I talked to my dad about it and like I understand why now children would be going to school and complete dark the summer. The sun would be coming up at 4am and going down at 7pm. So did you never realize that? No, I never put two and two together. Oh yeah, what life would be like if we didn't do this well, wasn't it originally for like farmers and stuff?
Ed Delesky, MD:yeah, um, well, as anyone who's listening will probably figure out by now, like this isn't our exact strong suit, I think it might have been in world war one. Um, for the farmers, who knows? Unsure unclear at this point. Send us some fan mail if you're shaking your fist, farmer, and you're a farmer, and you're like yeah, I remember that world war one, that's when they were doing like you don't really need sunlight anymore who doesn't?
Nicole Aruffo, RN:the farmers why, they have those big lamps. You know, everywhere, that's what people say. Who are these people?
Ed Delesky, MD:like these people on tiktok, you know I could afford to pay attention to more farmers, or I'm spreading misinformation right now, who knows? Who knows?
Nicole Aruffo, RN:Feeling wild on a Saturday, spreading misinformation.
Ed Delesky, MD:Yeah, well, that's about five minutes. What do you say? We get into it, let's get into it, okay. So what are we going to talk about today, nick?
Nicole Aruffo, RN:Today we're talking about treating depression.
Ed Delesky, MD:Yep. So if you didn't listen to last week's episode, I would probably recommend pausing, maybe going back and checking that episode out so that you have a really great foundation about what we're talking about here in this episode. But briefly, I just want to mention as a primer to continue this episode is that depression is a formal medical condition and it goes beyond everyday sadness. We talked a lot about what the specific definition of depression is last week, including its two week duration of symptoms. At least these symptoms can be long lasting and they can disrupt daily life, and treatment is crucial for improving quality of life and reducing the risk of suicide. So here we are Another trigger warning we will be mentioning suicide and passing here today, and so Nick, tell us a little bit about how we differentiate treatment options, like how are we looking at depression? Where do we get started?
Nicole Aruffo, RN:So there's three kind of classifications of depression mild, moderate and severe. So mild depression is the kind that just involves some symptoms without any kind of severe distress or impairment to your life, and I think our intern's going to chime in here. Treatment options include kind of just like watching it psychotherapy, and just like doing things that are good for you, like exercise and doing things that make you feel good.
Ed Delesky, MD:Yeah, why don't you tell us a little bit about moderate depression?
Nicole Aruffo, RN:Moderate depression is when something is involving some more symptoms, and then this is when one might have some suicidal thoughts, and this is the time when an antidepressant medication might come into play. And then severe is really when you're having all these symptoms that are so severe that they're interfering with your ability to function and like your everyday life, and this could um treatment could be a combination of the antidepressant medications and psychotherapy.
Ed Delesky, MD:Yeah, and one other thing that you'll probably come across if you go to see see your doctor or someone who's taking care of you is something called a PHQ-9.
Ed Delesky, MD:It stands for patient health questionnaire and it is a set of questions that are written on a piece of paper or on a computer and you answer them yourself and it's essentially a mood screening and it's also used as a scale. So the higher the score, the worse your symptoms are, and it's a way that patients can communicate with their doctors in a way that might be less intimidating Sometimes if you're in the quiet of your own head and then you can write these answers down, you can communicate how you're feeling a little bit easier than openly admitting that maybe you're feeling all of these things, and so you can track those things over time. Like just this last week I was able to say, hey, your score was a 17 when we started talking a month ago, and now that you've been doing therapy it's an 11 and you should really celebrate that and take solace that what you're doing is working. So that's the PHQ and that's really how usually we get to the mild, moderate and severe categories.
Nicole Aruffo, RN:All right, let's talk about those medications.
Ed Delesky, MD:So medication is a can be an extremely important piece of the treatment plan for major depressive disorder, and so there is a large umbrella of medications called antidepressants, and under that name and title umbrella there are several different classes. The most common class of antidepressant medication is called a selective serotonin reuptake inhibitor. There are several of these medicines, and there's very commonly prescribed medicines as well, and if you talk to a lot of people that you know, I bet a handful of them probably take these, but maybe they're just not advertising it. And so these selective serotonin reuptake inhibitors are abbreviated SSRI and they go by different names. And so for a fair and balanced conversation, we'll give the generic name and some brand names. Some names go by escitalopram or Lexapro is the brand name, paroxetine or Paxil, citalopram or Celexa, fluoxetine or Prozac and sertraline or Zoloft, and these are all very common medications. As I said earlier, they work by inhibiting the reuptake, as the name might suggest, of serotonin at the synapse. So when two nerves are communicating with each other in the brain, these medicines make for an increased amount of serotonin between those two nerves to communicate. Functionally, what they do is they help people cope with their situation. They themselves do not deal with the problems that someone may have that may lead to them having depression we will talk about the thing that does that later but they may make it easier for people to react to those situations, and so it's something we're going to talk a little bit more about some details.
Ed Delesky, MD:But to continue on, there are also serotonin norepinephrine reuptake inhibitors. This is a similar medicine, but instead of just increasing the amount of serotonin, it also increases the amount of norepinephrine. Some common names include venlafaxine, otherwise known by the name Effexor, and duloxetine, otherwise known by Cymbalta. There are other older atypical antidepressants and other related meds, including things like tricyclic antidepressants and monoamine oxidase inhibitors. These medicines aren't as commonly used anymore. They still may be used in specific situations, but those specific medicines tend to have more side effects like dry mouth, constipation, dizziness and urinary retention. For tricyclic antidepressants and the monoamine oxidase inhibitors or you may have heard of MAOI these require a lot of dietary restrictions, in the way that you literally need to change the food you eat because they may interact with these medicines, which make them a little cumbersome. One other medicine that's very commonly used, that's a norepinephrine and dopamine reuptake inhibitor, is called bupropion, and that's a very common one, well used and tolerated for people who have depression.
Ed Delesky, MD:So with so many options, there comes a point where you need to select a certain antidepressant, and for mild to moderate depression, there is a consensus out there that SSRIs are the first line treatment because they have similar benefit to the other medicines and they have the least amount of risk associated with them, including a lesser amount of risk for side effects, which tends to be very positive. There are the reasonable alternatives that we already discussed, and generally they all have similar effectiveness. When it comes down to it because even the SSRIs there is a long list up there that I gave you there are several different factors that eventually help narrow down which one someone may end up on. Safety and potential side effects. Some of them have certain side effects that others don't, and so maybe you end up leaning one way or another. Certain phenotypes or presentations of depressive symptoms may do better with certain types of antidepressants. If someone has other psychiatric or medical conditions, that may push someone to prescribe one antidepressant over another.
Ed Delesky, MD:A potential for drug interactions. How easy is this med to use? Is it dosed once a day, twice a day? Do you take it in the morning? Do you take it at night Once a day, twice a day. Do you take it in the morning? Do you take it at night? Some people have a family history of a relative having success on certain medicines. That's taken into account. Occasionally Cost and insurance coverage become issues and previous responses to prior antidepressants, and when you consider all of those, more often than not you land on one specific medicine that works well for the person. Nikki, I've done a lot of talking here. Can you take us through some side effects, knowing that for SSRIs there are many less side effects, but we want to have a balanced conversation here and recognize that sometimes there are. And so what could someone be looking out for if they are concerned about a side effect for an SSRI?
Nicole Aruffo, RN:So some side effects include sexual dysfunction, some reports of waking, dry mouth and also some insomnia, but typically these symptoms are most often mild and they'll go away within about a week or two.
Ed Delesky, MD:Yeah, I've recently seen that people sometimes will say like, oh, I took the medicine once and I didn't feel great, so I stopped, and I appreciate that they came back and told me that like this happened yesterday and I'm really happy they came back and invited me to be a part of that conversation.
Ed Delesky, MD:But, at the same time, these medicines can be very effective, but they have to be used correctly, and so, if you do have questions about side effects, ask your specific doctor, because each of those medicines may have slightly different variations, but that's a very broad overview.
Ed Delesky, MD:When thinking about these medicines, dosing is something important to consider. A low dose minimizes side effects, but it's important to make sure that you're following your doctor's instructions and increasing that dose when they say so, whether it be increasing at one week or in a month, because really a lot of times, because those dose adjustments tend to be very important, because, quite literally, the most common reason for people failing these medicines are because the medicines are at low doses or they are used irregularly, and so if you rely on your doctor or nurse who's taking care of you, they can help guide you through that process to get you at the right dose at the right medicine for the treatment that you're undergoing. Nikki, these medicines have a lot of conversation, like I mentioned, that lady yesterday I saw who said I took it one time it didn't really work. Tell us a little bit about the timeframe, about how these medicines work.
Nicole Aruffo, RN:So it will take some time for these meds to start working fully. A lot of people will start to feel better within maybe as little as a week or two, but really you have to give it a solid six weeks before determining if this medication is actually making you feel better and working for you this is such a common thing like I'll see someone, I mean that's a long time that is a long time so that can be frustrating, and I see why people wouldn't want to keep taking it, you know.
Ed Delesky, MD:Yeah, one thing I do worry about is to that earlier point where if people are taking, let's say, they're at six weeks, but they've been at the lowest dose of Lexapro and I worry that they'll lose faith in the treatment plan when there are like two more steps above that before they actually get to the treatment dose. And so, specifically, this is six weeks at the treatment dose, not at the starting dose, to see if you tolerate the medicine. So that's an important bit. And what other thoughts do you have about that? None, and I hear you. I think that that can be a tough thing for people to appreciate, because there are medicines that make you feel different immediately, like specific anti-anxiety medicines. You take them and then in minutes you feel less anxious. But this is the long run. This is almost like a vitamin for your mind, and so it's an important part of the treatment plan, but it ends up not being everything.
Ed Delesky, MD:Usually, when I'm with someone who's getting the depression talk from me I draw them a triangle and I draw them on. One arm of the triangle is medication, the next arm is therapy and the third arm is behavioral activation. Let's talk about the second arm, let's talk about therapy. So when I draw that triangle. I really try to emphasize and say that all parts of treatment end up making for the most effective treatment of your mood disorder. In this case we're talking about depression. Evidence will suggest that Psychotherapy, and specifically cognitive behavioral therapy, and medication are just as effective as one another. But there's also a preponderance of evidence that suggests that if you use both at the same time, you will have an even more effective treatment plan. And so there are multiple types of therapy.
Ed Delesky, MD:There are multiple types of therapy. It is not just like you're sitting on a couch with someone who has elbow pads and a mustache, divulging your life secrets to this person. There are many different types and we will define them here. There is cognitive behavioral therapy, or CBT. This type of therapy identifies and reshapes thought and behavior patterns. So let's see. One example of this would be someone who has a one-time herpes breakout and they, for one year, are terrified of engaging in a relationship with someone because they are so worried that they will pass it along to someone else. They've never had another breakout. The risk is relatively low, but they will not engage with another person. They won't even talk to someone that they're interested in because they are so terrified of the possibility of giving someone else herpes, and so one might suggest that that is a thought pattern that could be reshaped through cognitive behavioral therapy.
Ed Delesky, MD:There is interpersonal psychotherapy. I see this less frequently. This focuses on relationships and interactions with others. There is family, and many people have heard of this couples therapy. These address issues contributing to depression and family members or partners.
Ed Delesky, MD:There is something called problem solving therapy, which uses a systematic approach to solve practical problems, and there is psychodynamic psychotherapy, and that is the armchair sitting back with the elbow pads, with the person with the mustache, because that is exploring past life events to understand current behavior. So that was a lot and something really practical that we wanted to share on this episode is selecting psychotherapy, or how the heck do you get into therapy is the question, and so one easy point of access could be asking your primary care doctor. Many primary care doctors have behavioral health consultants that they work with or that they could refer you to, and that is a great access point. So first stop your primary care doctor. The second stop is something that I usually say every time I'm having a conversation with someone, and you can literally hop off of this episode after you listen to the full thing and after, you share with a loved one or a neighbor and you can go to this website. It's called psychologytodaycom and on this website you are able to see a breakdown of therapists. You are able to see their credentials, areas of special training, their mantra, the insurance coverage they take. You can see what they look like, you can see do they do online or in person, and in that way you can break down and find someone that's in your area, that you might be most comfortable with, accessible, affordable, and that you can be proactive in that next step and engage in your treatment more so. Once again, that is psychologytodaycom and it is available to you right on your phone, where you're probably listening to us right now, and so those are two options to get access as soon as either your next appointment or today See your PCP or psychologytodaycom.
Ed Delesky, MD:One comment to say about now. We've talked about two different arms of the treatment. We've talked about taking medicines and we've talked about therapy. We've talked about how they usually work better together, and when you go to therapy, you tend to work through some of these problematic thoughts that may be sticking around, causing certain your symptom pattern. Usually, it seems like therapy tends to last longer because you're getting to the root of the problem, but SSRIs can be very helpful for those who simply need them, and it's a very important arm of treatment. So I think the audience has been hearing my voice so much in this episode. We've talked about if I draw this triangle. We've now talked about medications, we've talked about psychotherapy, but let's talk about behavioral activation and other aspects of treatment for depression. Take us through exercise. Why is exercise so important for depression?
Nicole Aruffo, RN:well, when you exercise, you get endorphins, and endorphins make you happy, and happy people don't kill their husbands. Did you just come up with that on the spot or is that? No, it's from legally blonde. Yeah, when the um like exercise instructor was on trial for killing her husband oh my god, and then that's. That was like elwood's defense, but then she was right. It turns out that the daughter killed him, but she thought that it was the stepmom exercise instructor this has to do with the perm right, it was juicy.
Nicole Aruffo, RN:Yeah, yeah, I remember this, yeah um, yeah, so that's the basis of that. That exercise makes you feel good, and because it makes you feel so good, it's suggested to have 30 to 60 minutes of heart rate increasing exercise at least three times per week.
Ed Delesky, MD:And what about people who maybe aren't exercising so frequently?
Nicole Aruffo, RN:So that's just suggesting starting off with more gentle activities like walking. You can take your dog for a walk. Do some work around the house and the garden. You can do something, be productive and active at the same time. You'll feel great.
Ed Delesky, MD:Exactly, and I really would like to emphasize this point because this is something that, if you're listening to this and you're like I actually I do have depression you can get out there today and this isn't just something like, oh, I should exercise. When you look at it in the framework of this is a treatment plan. This becomes a part of your prescription and so now it's non-negotiable, like if you were to take a medicine every day. If you have high cholesterol, you have increased risk of heart attack and stroke. You would probably take your statin. If you had high blood pressure, you would watch how much salt you have in your diet. You would probably take your blood pressure medicine. If you have depression, you're probably thinking about taking your antidepressant.
Ed Delesky, MD:Finding and engaging in therapy. Exercise becomes a part of your prescription plan, and you almost have to force yourself to do this. If you're sitting at home, not doing anything, ruminating in, frankly, sadness, that won't help. So as a part of your prescription plan, you have to engage in some sort of exercise, whatever it may look like. This goes along with behavioral activation. Behavioral activation is a resumption of enjoyable activities that were because of the depression.
Ed Delesky, MD:Maybe you like to read and maybe you stopped reading because of the depression. Perhaps you did yoga. Maybe you get back to doing your yoga or go on walks, whatever that thing is. Take a long moment and reflect what could I do that I used to like to do, and then make yourself do it. This is so much easier said than done. There are huge motivation and concentration components to depression and its pathology, but this is the point is that in that triangle of treatment, you're getting out there and you start doing those things that you once liked to do because it's important and it will help you. Is that easier said than done? You think?
Nicole Aruffo, RN:Yeah, probably.
Ed Delesky, MD:And so, as we're wrapping up this episode here, I really want to highlight that there is hope and there are plenty of opportunities to be able to help yourself, even as soon as you're done logging off this episode, to treat depression, if that's something you're dealing with, also several other mental health disorders, and so think of that triangle the next time that you're considering how well are you doing? Are you taking medicine? Have you thought about medicine? Is that an option for you? Have you engaged in therapy? And how well are you doing on behavioral activation and exercise? And if you work closely with your doctor, you should be able to see some improvement. And if not, then keep going, keep trying to get help, because there is hope for recovery out there and feeling better from what is a really common, really important illness to consider. So thank you for coming back to another episode of your Checkup. Hopefully you were able to learn something for yourself, a loved one or A depressed neighbor.
Ed Delesky, MD:Please check out our Instagram, our website, send us an email yourcheckuppod@gmail. com. Send us some fan mail and, most importantly, stay healthy, my friends, until next time. I'm Ed Delesky. I'm Nicole Aruffo. Thank you and goodbye, bye, bye. This information may provide a brief overview of diagnosis, treatment and medications. It's not exhaustive and is a tool to help you understand potential options about your health. It doesn't cover all details about conditions, treatments or medications for a specific person. Thank you given or its use. This content doesn't endorse any treatments or medications for a specific patient. Always talk to your healthcare provider for complete information tailored to you. In short, I'm not your doctor, I am not your nurse, and make sure you go get your own checkup with your own personal doctor.
