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Interviewer: When depression or bipolar disorder isn't responding to standard treatments, they are referred to as treatment-resistant mood disorders.

Psychiatrist Dr. Brian Mickey from Huntsman Mental Health Institute's Treatment-Resistant Mood Disorders Clinic is an expert at treating these conditions, and today he's going to tell us how visiting a specialist can help people suffering from this condition live happier and more productive lives.

Dr. Mickey, first, when does a treatment-resistant mood disorder become classified as treatment-resistant?

Dr. Mickey: There's no kind of magic formula, but in most cases, we consider if you've had at least two adequate trials, meaning medication trials, psychotherapy trials, that are robust and that lasted long enough and you didn't respond, we would consider that treatment-resistant.

Interviewer: Either through medication or through psychotherapy, you would have to go through at least two of those. And if you weren't seeing an improvement of the symptoms, that would be classified as treatment-resistant.

Dr. Mickey: Right. Exactly.

Interviewer: Okay. When a patient comes to you after it being identified as potentially treatment-resistant, what are the interventions that you offer then initially?

Dr. Mickey: So some of the initial options that we would discuss would be changes to their current medication regimen. That would be a common one. Sometimes people haven't had an adequate treatment trial.

Another option that we would offer within our clinic would be transcranial magnetic stimulation. That's a non-invasive brain stimulation treatment.

We also can offer ketamine infusion therapy. That's an intravenous ketamine infusion that can be helpful for depression.

And so if these less invasive options aren't effective or cause too many side effects, then there are other surgical options that we sometimes will go to next.

Interviewer: Tell me more about the less invasive options. How long do you try those? How many of those do you go through before you kind of get to that point?

Dr. Mickey: That depends a lot on the particular patient, the kind of depression they're having, how severe it is, and, of course, insurance coverage. But typically for people who are functioning fairly well, they're going to work or doing their daily routines, then transcranial magnetic stimulation or ketamine infusion therapy can make the most sense.

Transcranial magnetic stimulation and ketamine infusion therapy are more compatible with maintaining your kind of regular daily routine and the side effects are relatively low for those as well.

For people who have had more severe depression that has been very debilitating or is preventing them from working, or let's say they're admitted to the hospital, then electroconvulsive therapy, or ECT, is what we would think of probably before those other treatments.

Interviewer: Are people intimidated by that name, the fact that you're using electrotherapy? I mean, that could sound kind of scary.

Dr. Mickey: Yeah, I think it can sound scary and if you don't know too much about it or if you only know what you've learned in the movies, then it's very scary.

Interviewer: And what happened like 100 years ago. It's not that anymore.

Dr. Mickey: Yeah, it's very different and it's a very safe treatment. It does have side effects and we counsel people about that, but it can really change the game for people with severe depression.

Interviewer: It sounds like you have a lot of options and tools at your fingertips to help somebody who has gone through some initial treatments and has not been able to handle the symptoms, take care of the symptoms in a way that they're able to go back to their life.

Tell me about a typical patient that walks into your office. Describe what that looks like and the conversation you have.

Dr. Mickey: So a typical patient that we see would come feeling pretty hopeless, I would say, because they've tried many different kinds of treatments and feeling like they've gotten to the end and they don't know what else there is to try.

Typically they've had years of illness, if not decades. And most people that we see also have had this illness since they were very young. So, most of the time, the onset of their illness is in their teenage years or young adulthood.

Typically, people are not able to enjoy life. They're not enjoying their work. They're not enjoying their social interactions. They become less interested in pursuing hobbies and being with other people. Most people have then become kind of socially disconnected, and that can even make things worse, because that's . . .

Interviewer: Yeah, and not finding satisfaction in work. Do these individuals realize that this is happening and are like, "I would love to find satisfaction in my work, but I just can't"?

Dr. Mickey: Right. Most people do, and the way they experience it is usually they're not sure why they're not enjoying it. And of course, we all have stress in our lives, but these are situations where the amount of sadness and mood dysregulation and loss of interest and pleasure is far beyond that. It doesn't make sense in the context. That's kind of what we're talking about here when talking about depression.

Those are the kinds of experiences and symptoms people are having before they're coming to our clinic. And what these treatments can do is they relatively quickly, within a few weeks, start to relieve people of those symptoms. And then the effects can last for months or sometimes even years before people will very often have a relapse.

And so that's something that we also educate people about. This is not a cure. It's a treatment that we can administer for this episode. But that can be a really meaningful difference for people.

Interviewer: And then if a relapse occurs, what then?

Dr. Mickey: For people who've had a recurrence, then we can oftentimes use these same treatments. And so we don't think of them as permanent fixes obviously. And so people will always have this kind of vulnerability. That would be the most typical pattern, that people have recurrences.

But if you understand the patterns, sometimes you can prevent them. That's the ultimate goal, is to prevent a recurrence. But if people do have a recurrence, then we can use these treatments again. And so those are the folks that we see and that I think we can help.

Interviewer: And for those individuals that have suffered for decades, what's the barrier to seeking out more treatment?

Dr. Mickey: There are a number of barriers. One is not knowing about what options there are beyond the things they've already tried. Another is oftentimes just insurance barriers.

Another barrier that people have I think is just fear of the unknown, kind of maybe not quite understanding what these treatment options are really like, which we can help educate people about that.

And then I think another is just that a lot of times people don't want to be a depressed person. It's not a great place to come from. And so you have to sort of admit that you have this condition before you're really going to come to the clinic. I think that can be a barrier as well.

Interviewer: Do you find it common that somebody that is suffering from a treatment-resistant mood disorder is not able to seek out help on their own and generally a family member is needed?

Dr. Mickey: It is pretty common. And I think part of it is that they may not want to think of themselves as a depressed person or they may not realize in some cases how severe things are.

And that's one thing that depression does, is it changes how you see yourself and how you think about the world. It makes you more kind of internally focused and less able to appreciate how far things have gotten in many cases. And I think sometimes people just don't remember how they were when they weren't depressed. So it has these effects on your own cognition and understanding of yourself, which kind of makes it unique.

Interviewer: You mentioned insurance can be a barrier for some people. Is there somebody at Huntsman Mental Health Institute that if somebody is concerned about "How am I going to pay for this?" that could help walk that individual through maybe some of the options if insurance isn't the option?

Dr. Mickey: Yeah, absolutely. In our clinic, we have referral specialists who will do all of those checks ahead of time and help you understand what the financial situation is. You don't want to go into a situation like this and not know what the cost will be. And there's nothing like an extra bill to accentuate your depression. So, yeah, that's an important aspect of the care that we pay a lot of attention to.

Interviewer: Well, it sounds like that you are offering hope to some people that have struggled with mood disorders for a long, long time. As we wrap this up, is there anything that you would say that you would like the listener to take away from our conversation today?

Dr. Mickey: Yeah, I would say that there is hope. And that's a very common reply or response that we get from patients at the end of a consultation. They're often saying, "I didn't even know there were all these options." It's pretty common actually for people to feel quite a bit better just after this single consultation visit before we've even administered any active treatments.

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Scot received two at home genetics testing kits last Christmas. He wanted to share his second test, but producer Mitch had already taken one, and Troy was adamantly against taking the test. He decided to give away his second test to one of our listeners. Seemed simple, but over the past month the Who Cares guys have been looking deeper into the realities of consumer genetic testing. What they've found is worth talking about.

The winner of the competition is listener Matt. Matt is a father with one young daughter and a son on the way. Matt wanted to take the test because he was curious about his genetic predisposition of certain health conditions and the likelihood of passing them on to his kids.

Karin Dent is a certified and licensed genetic counselor at the University of Utah. We brought Karin on to discuss with Matt the realities of consumer genetic testing and have a conversation about whether or not he still wanted to take the test. You Cannot "Un-know" Your Genetics

The first question we asked Matt was whether or not he had read the terms of service for the genetic test. He had not. It was important to share one term that many people don't think about when it comes to their genetics:

Once you obtain genetic information, the knowledge is irrevocable. You should not assume that any information we may be able to provide you whether now or as genetic research advances will be welcome or positive. You may learn information about yourself you do not anticipate. This information may evoke strong emotions and has the potential to alter your life and worldview.

According to Karin, this is something a person should think about taking the test. The goal of genetic counselors is to help people understand the medical, familial and psychosocial implications of genetic data and how it can impact their health and overall well-being.

She explains to her clients they can't "unknow something." Once you learn you may be genetically predisposed to a health condition, you will always know that bit of information. It may change your life in ways you don't realize.

Karin says as a patient and consumer, you have the right to not know something just as much as you have the right to information about yourself. A DNA Test May Not Provide the Answers You Seek

The main purpose of genetic counseling is to make sure the patient is fully aware of the limitations, benefits and risks associated with genetic testing. Many people are like Matt, and looking for a potential genetic predisposition they may have. Unfortunately, genetic tests today don't test for every single condition.

Karin suggests that if a person is wondering if there is a specific genetic condition you are curious about, make sure the test you are taking actually provides results for that condition. Tests may be limited in the diseases and conditions they test for. No test on the market covers everything. Additionally, most tests available will only provide results for a small subsection of known genetic factors that may contribute to developing a condition. Your DNA is Not Your Destiny

Matt is specifically curious about conditions like Parkinson's disease as well as a predisposition to obesity and diabetes.

Most conditions these at-home genetics kits report on are complex conditions that form in adulthood. While there may be a research backed genetic predisposition for these conditions, lifestyle and environmental factors play a large role in whether or not a person will develop the condition.

"[The test] gives you an assessment," says Karin, "but it isn't a black and white result."

Despite how these tests are marketed, there is more involved in the development of a condition like obesity.. While a limited set of genes may suggest a predisposition, the diet and lifestyle of a person likely plays a bigger role in whether or not a person becomes overweight.

"One thing I like to tell everyone I meet with, patients, clients friends, is that your genetics is not your destiny." says Karin "Even if this came back and said you have an increased risk or there's an increased association with obesity based on the genetic factors that you have, remember, that is only a small subset of the genetic contributions we know currently that contribute to obesity."

There's a limitation on the information genetics test can provide. The results are not - and should not - guide your healthcare plan. These test results should not replace routine healthcare screenings. Just because your genetic results say you have a reduced chance of developing prostate cancer, that doesn't mean you should stop getting your screenings.

As such, some professionals have begun to refer to direct-to-consumer genetic testing as "recreational genomics." Meaning, the results of the test may be interesting, but shouldn't guide how you approach your health. You Are Ultimately Testing Your Whole Family

After getting your genetics results, you may be faced with not only a personal dilemma but an ethical one as well. If you found out you have an increased risk of a certain cancer, that can have a huge impact on your relatives too.

"When you take a test, you're testing a family," says Karin.

It's rare that a genetics test will find something that only impacts one person. You share much of the same genes as your parents, siblings, and children. The results you receive may be present in others. Some members of the family might not want to know. On the other hand, if you find something is there an obligation to tell the rest of the family? It's important to consider what you are willing to share with these people, and how it will impact them

Matt has had discussions with his wife about how this information may impact their family. She might have to deal with his genetic results as a wife, and as the mother of their kids. The two of them have discussed how they would approach those topics as a family. He is also considering how he will share his results with his brother. There Currently Isn't a "Professional" Option

Direct to consumer testing is unique in the genetics world because it is a test that targets healthy people. These tests are often marketed as a way to keep healthy people healthy by giving them knowledge about themselves so they can take the steps necessary to prevent different health conditions.

Clinical genetic testing isn't typically for "healthy" people. Clinical testing is used to find the cause of a severe health condition or birth defect already present in a patient. There currently isn't a readily available clinical test for healthy people who are merely curious about their genes.

There are "adult healthy screens" available in some clinical settings, but these are often very specific tests that are screening for specific conditions for rare circumstances.

With this in mind, genetic counselors do not typically suggest getting an at home test due to the limitations of the information these tests can provide. Consumer genetics testing companies are ultimately targeting you as a consumer, not a patient. There Is No Rush to Get Tested Today

Karin personally refuses to take an at-home genetics test despite her genealogically minded father's urging. For Karin, she feels there are too many limitations in the testing right now and the information it may provide is not of any value to her.

"[A direct-to-consumer genetics test] is not going to tell you anything that will change your life in a positive way," says Karin. She has met with people that have regretted what they have learned from these tests. They feel that it has changed a part of their life that they can't get back. There's a time before they learn something, a time after.

With that in mind, Karin explains that there should be no rush to go and get your DNA tested today. Unlike a lab value, your genes don't change. You will have the same genes five, ten, fifteen years from today. As genetic research advances there may come a time when the results given by genetics testing will be more valuable - and perhaps cheaper. There's no reason you can't wait to get the test later in your life. Will Matt and Scot Take the Test?

After all of this discussion with a professional, it comes down to this: Will they still take the test?

Matt still wants to take the test. He has spent a lot of time considering the realities of this kind of testing. He understands the limitations. He understands he can't unknow his results. He knows his test will impact not just him, but his whole family.

But for Matt, he reasons that he's still young. Knowing his genetics may be able to help him better understand steps he can take moving forward in his own life. He's thought about what he would do with the information and his kids. He's making an informed decision about his genetics, and that's what Karin supports.

After spending the last few months considering it, Scot has decided he isn't going to take the test. For him, he was moved by Karin's discussion of not being able to "unknow" something. He works hard to live a healthy life. He has a good understanding of his family history. He feels that there is nothing the test will tell him today that would positively impact his life.

Scot may consider taking the test in the future, but he recognizes that there's no pressure to take the test today just because it's trendy. Just Going to Leave This Here

On this episode's Just Going to Leave This Here, Scot challenges Troy to guess what's wrong with his ear and Troy hates shaving so much he jokingly considers laser hair removal. Talk to Us

If you have any questions, comments, or thoughts, email us at hello@thescoperadio.com.

Seasonal Affective Disorder is not the same as winter blues. Ignoring your symptoms could make the holiday season less than jolly.

I'm Jason Hunziker, Psychiatrist at the University of Utah. And that's what coming up on The Scope.

Often with the winter blues even though you're feeling down and sad, your emotions can change based on the environment that you are in. If you're watching a show that's funny or happy you can laugh, or if somebody tells you a joke you can get happy or it's fun to out with your friends and it's still fun to go skiing, but other times you're feeling down and stressed.

With seasonal affective disorder your mood doesn't generally change. Things don't make you happy anymore and you don't find pleasure in those things that you used to find pleasure in. You're interest level drops and you prefer to stay by yourself rather than be around other people. Often you feel you are pretending to be happy just so that others around you won't know how sad you really are. The difference is the symptoms last longer, they are more severe, and they impact all aspects of your life.

Sometimes the patients are able to go through the whole winter without any treatment and it doesn't cause much disruption. However because this is a sub-type of depression, it can lead to more significant symptoms and problems.

This is different than just feeling the so called winter blues or seasonal funk as some people will say, because it actually impairs your life and the life of those around you when you have this type of depression.

The way that this can affect others in your life is that many of these symptoms of depression include isolation, avoidance, irritability, poor sleep, overeating, weight gain, sadness, crying episodes, all of those things which can impact your family and friends and coworkers.

The cause of season affective disorder is still not clear; however there are a few theories on how this illness comes about. One of those theories is the biological clock or circadian rhythm suggesting that because of less sunlight in the fall and winter you are more likely to have moments of depression and sadness.

Another theory is that melatonin levels also change when seasons change and then based on your melatonin production or melatonin levels you will also experience changes in your mood pattern.

And lastly serotonin levels are always looked at when we're talking about depression and changes in the serotonin particularly around stressful times such as the holidays can increase people's sadness and difficulty in coping with stress.

The literature would suggest that women are at a much higher risk of this illness than men; however when men do get seasonal affective disorder their symptoms are much more severe and place them at higher risk of self harm and suicide.

Those of us who live further from the equator are also more at risk, mainly because the changes in the dark and light patterns in our seasons make us more at risk. If you have a family history of someone with depression or anxiety or substance use disorder, you are also more at risk of this sub-type of depression.

The most common age that we start to see seasonal affective disorder is sometime around 20 years old. The age range generally is between 20 and 40; however depression can come at any time during your life. And if you do notice the symptoms of seasonal affective disorder what are you going to do about that? I think the important thing is to go in and talk to your primary care doctor, your family practice doctor, your nurse practitioner or whoever your healthcare provider is so that you can get the appropriate care and treatment for this syndrome.

The important things that you should talk to your doctor about when you recognize that these symptoms may be more than just the winter blues include when these symptoms start every year. If you notice that every year in September you start to have trouble sleeping, eat more, have trouble moving around, that's important for your doctor to know.

Looking at your history and telling your doctor how long these symptoms have been present, if it lasts from September to December, or if you've ever been suicidal, or if you notice you're drinking more alcohol during that time, it's very important for your doctor to know. If you have family history about depression, bipolar disorder, other mental illness your doctor should also know that as well.

And then after this appointment your doctor may suggest to you several different types of treatment. One of the most commonly recommended treatments for seasonal affective disorder is light therapy. Even though this treatment is not FDA approved, there is a lot of anecdotal evidence that the light therapy will work for this illness. Light therapy is composed of a box that sits on your desk or that you can carry with you that essentially is bright light that shines into your eyes for anywhere from 15 minutes to 2 hours a day to help you with your mood symptoms; based on the theory that the change in the amount of light that we get every day this treatment will help improve your mood symptoms.

Additional therapy could be medication use including SSRI medications like Prozac or Paxil or Zoloft or other medications like Wellbutrin that can be taken during this period of time that you have your symptoms and then with the help of your doctor you could come off of those medicines for the remainder of the year.

The holiday can be very stressful, family parties, family get togethers, seeing people that you really don't want to be around can be stressful at this time and having someone you can go to and talk to about these symptoms is very beneficial for most patients.

updated: December 21, 2021
originally published: December 10, 2014