Rethinking Depression

Growing up in New Castle, Brenda Weingartner, 53, was a teenager when she had her first of many bouts with depression. “Back then, my parents didn’t have a good understanding of mental illness and what to do for it,” she said. “My mother’s suggestion was to go talk to the minister. That was her generation’s solution to the issue.”

By the mid 1980s, she took her cousin’s advice and went to see a psychologist, but lasted only a few sessions. “He basically patted me on the head and said, ‘You know, you just need to think happier thoughts’ and referred me to a couple of books to read.” As a graduate student at Kent State in the early ’90s, her depression worsened, and she began seeing a counselor weekly. A year later, she reluctantly tried her first anti-depressant. Once back in New Castle and working on a career as a high school English teacher, she enlisted the help of both a psychologist and psychiatrist. By 2009, she had found the right mix of treatments that have kept her depression-free ever since. “I know there’s no cure. It’s not that I never have a blue period. I’m just like everybody else. But it is nothing compared to the lifetime I spent being depressed.”

Battling the blues

Weingartner’s life parallels the decades-long fine-tuning of treatment for major depression—recently ranked by the World Health Organization (WHO) as the No. 1 cause of disability worldwide. It affects 25 percent of women and 10 percent of men at some point in their lives.

“We’re still in a learning phase, but we’re providing much better evidence-based treatment,” said Joseph Cvitkovic, a psychologist for 30 years and director of Behavioral Health Care at Jefferson Hospital, part of Allegheny Health Network. “I think people would be pleasantly surprised to see how far we’ve come in our ability to help them through this.”

Despite better treatments, fewer than half of those affected in the world (in some countries, fewer than 10 percent) receive such treatments, according to the WHO. Men, in particular, are less likely to seek help. Cvitkovic believes they are more likely to feel that depression represents a sign of weakness and try to muscle through on their own. “Though there are still more women in treatment, the frequency of men coming into treatment is higher today than it’s ever been and that’s a good thing.”

Dying of a broken heart

Discussing depression with Pittsburgh-area experts, it is hard not to notice a collective sense of urgency to inform sufferers to seek help. While we know depression can play a direct role in suicide, it also plays a hand in the most pressing health conditions—heart disease, dementia, diabetes and cancer.

“People literally can die of broken hearts. The notion of mind-body separation really doesn’t make any sense,” said Dr. Charles F. Reynolds III, a geriatric psychiatrist and director of the Aging Institute of UPMC Senior Services and University of Pittsburgh. “The point that often gets lost is that depression is an unwanted co-traveler with heart disease and diabetes. A good one-third of people living with heart disease and diabetes also have clinically significant levels of depression. Depression amplifies our disability, undermining adherence to prescribed treatment as well as lifestyle changes that would be helpful to ameliorate heart disease or diabetes. And the combination shortens life expectancy as well.”

A longtime depression researcher, even Reynolds was taken aback by the results of one of his recent studies, which followed 1,200 older adults receiving care at 20 primary care practices in Pittsburgh, Philadelphia and New York City. After eight years, the patients who had been treated for depression were far less likely to have died from cancer. There was a 24-percent reduction in mortality risk among those who had received evidence-based depression treatment. “I was surprised by the magnitude of the findings,” he said. “But it was also gratifying because it makes a lot of sense. We don’t know the mechanism of how depression treatment might reduce deaths due to cancer. Though there’s no direct evidence, it may be that depression speeds cellular aging and effective treatment slows cellular aging.”

Your brain on depression

Just a decade ago, researchers knew very little about depression’s impact on the brain. Now, it’s becoming clear that “depression, especially in older age, doubles a person’s risk for later developing dementia,” said Meryl Butters, a University of Pittsburgh neuropsychologist whose research focuses on late-life depression. “People shouldn’t live with untreated major depression. It’s important to treat it aggressively and quickly. We haven’t proved it yet, but the data suggest that depression is neurotoxic in the brain.” What hasn’t been ruled out is that Alzheimer’s disease and depression could stem from the same neurological defect, or perhaps medications that treat depression contribute to the additional risk of dementia. “But most researchers think that’s not the case,” Butters added. “There’s something about what’s happening in the brain when people are depressed that increases the risk for dementia.”

Butters and fellow researchers have found intriguing early clues about depression’s toll. They looked closely at a group of 80 depressed older adults (mostly women, as with almost all depression studies). They scanned the research subjects’ brains, conducted in-depth cognitive evaluations and ran blood tests that measured 242 proteins (all related to biological processes important in the development of neurological and other diseases that are more common as we age). They found that depressed people with mild cognitive impairment (not yet dementia) had, among other things, high levels of inflammation and the stress hormone cortisol, signs of small strokes in their brain’s white matter and a smaller hippocampus (part of the brain important for forming new memories).

“There are a lot of cortisol receptors in the hippocampus. So if someone is producing too much cortisol, we think these receptor brain cells get overwhelmed with too much activity and die. As a result, the hippocampus shrinks,” Butters explained. In other words, “if you enter your older years with a smaller hippocampus because you’ve been depressed, you will be more vulnerable to symptoms of Alzheimer’s such as memory loss.”

Hurt hearts

Louis Pasteur’s quote “Chance favors the prepared mind” has been something of a mantra for University of Pittsburgh professor of medicine Dr. Bruce L. Rollman. In 1998, when he was just getting his career going at Pitt as a primary care physician and researcher, Rollman happened to notice a Pittsburgh Post-Gazette article summarizing a large study reporting that women fare worse than men following coronary artery bypass graft (CABG) surgery. That same week, Rollman was a dinner guest at the home of a mentor, Dr. Charles “Chip” Reynolds. “I was making small talk with Chip in his living room and happened to ask, ‘Did you see this article about women doing worse than men after bypass surgery? I wonder if it’s because depression is more common among women?’”

The study had not taken depression into consideration and Reynolds replied, “Someone should look into it. Why not you?” Since that conversation, Rollman has secured millions of dollars in federal grants and published dozens of studies on depression. His research shows how screening for and treating depression in heart patients can bring significant cost-savings and improve the quality of lives. “We found that telephone treatment of depression by our study nurses after CABG surgery saved over $2,000 in Medicare, UPMC and Highmark insurance claims per person treated in the year after surgery and produced more quality-adjusted life years (a measure to assess the value of a medical intervention),” Rollman said. “Outside of flu vaccines and prenatal care, there are very, very few things we do in medicine today that both generate more quality-adjusted life years and save money.”

(Learn more about the study at www.bypassingtheblues.pitt.edu.)

Another Rollman-led study found that hospitalized heart failure patients who screened positive for depression were three times more likely to die in the year following discharge from the hospital, compared to a similar group of patients who screened negative for depression. In his latest research endeavor, The Hopeful Heart Trial, Rollman hopes to answer: Can treating depression in patients with heart failure help these patients live longer? The five-year study, funded with a $7.3 million grant from the National Heart, Lung, and Blood Institute, is recruiting 750 patients from several UPMC-affiliated hospitals and could have far-reaching implications.

Nearly 6 million Americans live with heart failure and about a quarter of them suffer from depression. What excites Rollman most about his research is that his telephone-delivered depression intervention is relatively inexpensive and easy to provide compared with many cardiac treatments. The intervention has a nurse care manager regularly call a patient to educate him or her about depression, suggest treatment options, promote healthy lifestyles and monitor the patient’s condition under the guidance of the patient’s own primary care doctor. This type of collaborative care—at the heart of the Affordable Care Act and Patient Centered Medical Home—holds the promise of providing better care and improving health-related quality of life, all while reducing mortality and per capita healthcare costs, Rollman said.

Coaching away depression

At last count, there were 26 antidepressants available. But no new drug (only tweaks on old drugs) has emerged in 20 years. Mental health counseling, however, has made progress. Today’s counseling is far removed from the days of psychoanalysis some 40 years ago. “Today, there’s a lot more than just talk in an office,” said Cvitkovic. “You want to leave your therapist’s office with something in your hand indicating something to do and steps to help you make changes to your behavior. This is what makes all the difference in the world. I tell my patients that the longer I’ve done this, the more I recognize that I do more coaching and helping them not only learn about themselves, but learn what they can do to more effectively help themselves. We work as a team.”

For Weingartner, finding the right combination of treatments proved to be the end to her lifelong struggle with depression. But she also credits the support of family, friends and health professionals. “Depressives lose perspective,” she said, “and those individuals offer feedback and a more objective point of view. Through counseling, I learned to be able to recognize the signals that something was starting to go wrong. So then I’d get in touch with Dr. [Patton] Nickell [her Allegheny Health Network psychiatrist]. I’d call him or email him and ask, ‘This is what my symptoms are. Do you think I should increase my medication dosage?’ He was always so wonderful about working with me. Between him and Cathy Clover [her New Castle psychologist], the two of them saved my life.”