Search for tag: "depression"

Interviewer: You've likely heard of postpartum depression in regards to the mother of a new baby. But did you know as many as 10% of fathers face their own sort of postpartum depression? And it can happen before or after their child is born. But unfortunately, men are unlikely to discuss it or get support. And untreated, it can impact the emotional health of the father and his ability to be available for his baby and the mother.

Jamie Lea Hales is a licensed clinical social worker, and she specializes in helping couples with their mental health during and after pregnancy. I didn't know postpartum depression was a thing that men could have. Does it have a particular name when men have it, or is it just male postpartum depression?

Jamie: Actually, it really doesn't have its own special name. You would think that it might, but the reality is we just refer to it as perinatal mood and anxiety disorders because it can hit moms, dads, partners, grandparents, and caregivers really just in general. So it's much more broad than I think we initially realized.

Interviewer: And what causes it?

Jamie: I think it comes from a combination of life stressors, changes, loss of identity, and also the fact that your brain can change as you become a parent.

Interviewer: Wow, that's really interesting. So is it all in the brain? Is it all chemical related or are there other factors that can contribute to male postpartum depression?

Jamie: Outside of the changes to the brain, realistically when you have a new baby enter your life, whether it's your first or your fifth, there are going to be some compounding psychosocial stressors that come along with that. It is one of the biggest changes that you can go through.

Interviewer: And what kind of stressors are the most common to contributing to perinatal mood disorders or postpartum depression in men?

Jamie: First and foremost, lack of sleep. I cannot hit that one enough because it is the thing that I see over and over again. If you are not taking care of yourself, if you're not getting enough rest . . . And when I mean enough rest, I mean four- to five-hour chunks at a time. For both parents, this is probably the key to keeping yourself well.

Interviewer: Are there other types of stress guys talk about that can lead to male postpartum depression?

Jamie: When we look at some of our male patients, the pressure to provide financially can actually increase stress quite a bit because there are dueling priorities between being home, helping out, and being more involved, which we are seeing a lot more men being more actively involved in their child's caregiving, but also the dual pressure of having to be at work as well.

I mean, I don't want to completely gender that because that can 100% be the reverse as well. But it's just a lot.

Interviewer: And I've heard another major form of stress for men can be these expectations about what it's like to be a father or the kind of father they want to be. Can you tell me more about that?

Jamie: We all have this idea maybe in our heads of what parenting is supposed to be or should be. And when you actually get into the thick of it, a lot of the time, it doesn't line up with exactly what you thought it would be. And so there can be kind of an interesting grief reaction.

If you had a difficult relationship with your parent, you may have a lot of pressure on yourself to do better than they did. Or if you feel like you had the ideal parenting situation and it's not . . . And some people do. I mean, some people really do feel like, "My dad was the best. He was the best that I could possibly hope for." And then when they feel like they're not living up to what those expectations might be, that can be really, really difficult for people to accept.

And it takes some time I think, especially if you're not going to therapy or talking with somebody openly about this, to be able to resolve and say, "Okay, but I get to decide what type of parent I am going to be," and whatever that is, is okay.

Interviewer: Right. It doesn't have to be what you see on TV or in the magazines or what the guy down the street is doing.

Jamie: Absolutely.

Interviewer: We create those own realities ourselves.

How do most men experience this when they describe to you how they're feeling? What are the words they use?

Jamie: A lot of the time, it's just "I'm not feeling like myself." There's a loss of identity, I think, coming into being a parent.

And some of the symptoms that we see more frequently with men is irritability. Lots of "I've been really snappy with my partner a little bit more, just quick to anger in general."

We also see an uptick in use of substances. So more frequent use of whether it's prescribed to things that they've been given to help with sleep or anxiety, or even just increase in alcohol use because there is that stress and trying to figure out how to kind of mellow out. That's something that we see pretty frequently.

Interviewer: Are some fathers more likely to be impacted by male postpartum depression than others? Are there some things we know?

Jamie: Definite risk factors are preexisting mental health conditions. You are far more at risk for experiencing a PMAD if you are already struggling with mental health conditions.

Now, that being said, it does not mean that it will necessarily get worse. It's just something to be very much aware of, which is why we talk about a lot of this from a preventative standpoint.

Also, if you are somebody that has struggled with depression or anxiety prior to having kids, staying on your medication and continuing to work with that is going to be pretty key.

Another risk factor that I would definitely want to touch on is when a pregnancy is unplanned or unwanted and you haven't had adequate time to truly process through that and kind of wrap your head around it, that can be a risk factor as well.

So I highly encourage people who are in maybe a situation that they're not 100% sure about to talk with their partners about it well in advance during the pregnancy so that you can work on communication and really just work on trying to set yourselves up for a healthy plan for self-care once baby actually gets here. It's important for both people, and I always like to include both partners as much as I can in our process.

Interviewer: At what point, if a guy recognizes some of the symptoms you talked about, should he be concerned and seek some additional help to get some tools to help get through this time?

Jamie: If you notice it at all, if it's really impacting your day-to-day life, it's impacting your relationships, impacting your work, that's a great time to reach out and get some help. I think that there is benefit potentially to getting on the internet and looking at some just online resources, just trying to understand it better and get some education.

Interviewer: And of course, make sure that the resources you're reading are reputable from medical institutions, that sort of thing. Are there other resources online you like?

Jamie: The online resources I do really enjoy because I think it's a good way for dads to find a community of people who are struggling with the same things and are being open about it without having to search too hard or run the risk of feeling like the person in their life is just going to say, "Well, suck it up."

If it looks like it is getting worse or you just don't quite know how to wrap your head around it, I think that speaking with somebody who is in the mental health field could be very warranted.

This is a really common thing. We see this. Statistically, it could be 10%, but I think it's much higher than that. So please reach out for help if that's something that you feel like you could be struggling with or even if you're just unsure. There is no shame in that.

Interviewer: For men that aren't quite to the point where they feel they need to see a professional, you've talked about an acronym called SUNSHINE that can help with postpartum depression. Does this apply to both women and men?

Jamie: Absolutely.

Interviewer: All right. Let's go through this, because this is a tool right now that our listeners could take away and start implementing right now and see if it helps. So let's talk about SUNSHINE.

Jamie: One of the wellness acronyms that we use quite frequently in our work is actually SUNSHINE. So what it is, is a series of different things that you should be thinking about when it comes to your mental and physical well-being during pregnancy and the postpartum period.

So it stands for sleep, understanding, nutrition, support, humor, information, nurture, and exercise. So those are all points that I think would be helpful in the preparation phase for having a kid, to think about, "How am I going to still try to get some of these things?"

And it's going to vary depending on where you are in that process. During the early stages, your focus may be on one of those things. And throughout the process, it might be able to expand into something else.

So I always advise my patients not to think about it as if you're not doing each and every one of these things, you're failing at your postpartum experience or you're failing at therapy. But just make sure that you are keeping them somewhere in the back of your mind because you are still an important person and your relationships are still important, whether you've got a baby in the picture or not.

Interviewer: So just give us one sentence for each one of the items in SUNSHINE. So sleep.

Jamie: Four to five hours as often as possible. Uninterrupted.

Interviewer: Uninterrupted. And try to get the standard eight to nine, otherwise?

Jamie: Absolutely, if you're able to. What that will likely look like, however, is especially in the early days taking turns potentially with your spouse, because they also need that time.

Interviewer: What about understanding? Expand on what that means.

Jamie: Understanding can mean a couple of things. You could again reach out and try to get a better idea of what other people's experiences have been like. Or you could also just get some education around what perinatal mood and anxiety disorders actually are.

Interviewer: And then what about nutrition?

Jamie: Nutrition, that's a tricky one. So this is not a great time to start a brand new diet plan. It's probably not going to be the top of your list of things. What we do want to make sure is that you are making sure you're actually eating and fueling your body. It's really, really easy to put your focus all on everybody else and sort of forget that you have needs also.

Interviewer: All right. So make sure you're eating and try to get as much nutrition as possible, knowing that maybe you might have to use some convenience foods.

Jamie: Absolutely. And preparation going into this can be really helpful for that, making sure that you do have some healthy things around the house. But I'm certainly not going to judge you if the thing you ate for lunch was a bag of M&Ms. Just get something in your system if you can.

Interviewer: Support.

Jamie: Support is something that we should start generating right from the get go, whether it's our family, improving our communication with our spouse, whatever that looks like. It's good to try and bring your support system in as long as that's a safe thing for you to do.

Interviewer: All right. And humor. Crack lots of jokes?

Jamie: Definitely. Hey, dads are known for their dad jokes, right? That's a thing for a reason. But being able to laugh at the situation sometimes really can help. Not only does it increase your endorphins and just make you feel better in general, but sometimes being able to find humor in the absurdity that can come along with parenting is not a bad thing to do.

Interviewer: Good tension release a lot of the times, yeah. Information.

Jamie: Information. Get good information about these things. Get good information about your mental health. When I say go to online resources, I think finding ones that are specific to dads' mental health through Postpartum Support International are great. I would suggest don't go down the social media rabbit hole of things that will probably make you feel worse about your parenting.

Interviewer: Does information also include just learning more about what it is to raise a child?

Jamie: Absolutely.

Interviewer: Because to me, that would be a major stress point. I have a friend that I don't know how many books he read before his child arrived, and he said it just made him feel so much better.

Jamie: Yeah, I think it can be a real help to people just having a better idea of what that could look like. The caution I will put on that is that there is a perspective for pretty much anything you can find out there. So maybe get some guidance from your pediatrician before you just delve into something.

Interviewer: Yeah, make sure you're getting some of the good books. Nurture.

Jamie: Nurture comes back to the self-nurturing piece of this. It is okay to talk about how you are feeling.

Interviewer: And feel. It's okay to feel. A lot of guys struggle with just even doing that or identifying what the emotion is.

Jamie: Yeah, absolutely. Or feeling like a dad in general. It's a big shift and we want to make sure you're taking care of yourself.

Interviewer: And it's okay to say, "Hey, I'm doing okay. I'm an okay dad." I mean, if you can't say, "I'm a great dad," go with, "I'm an okay dad," I suppose.

Jamie: Being a good enough dad is good enough. It's different for everybody. And people always balk a little bit about that idea, but there is a whole theory around the good enough mother, and so we do actually talk about that quite a bit. Dads fall into that category too.

Interviewer: And finally, in SUNSHINE, you have exercise.

Jamie: Again, I'm not saying go out and start a whole brand new plan and get a gym membership and do all the things that you've been trying to accomplish, but get some movement. That movement can just be going out for a walk once a day just to get some vitamin D and stretch your legs.

Interviewer: It's good for the body and the mind.

Jamie: It is.

Interviewer: Exercise, like you said, releases all those endorphins and makes you feel good, helps reduce that stress.

If those things aren't working, what's the next step that you would recommend a man take?

Jamie: I would recommend reaching out to even if it's just your primary care physician to say, "I'm struggling with this. This is hard." If you are actively involved in child's doctor's appointments, you could even talk to your kid's pediatrician about how you're feeling. They have a lot of really great resources.

Interviewer: Jamie, this has been a very informative, great conversation. I know it's going to help a lot of dads-to-be. Any kind of final thoughts as we wrap up this conversation that you would really want somebody to take away after listening?

Jamie: There are times when you're in the early stages where it just feels like everything is falling apart, but you're definitely not by yourself. You're not the only one that has struggled with becoming a parent or feeling like it's going to be like this forever. It's truly not. Get some support, and at the end of the day, it will get better and you're not by yourself.

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.

Interviewer: You've already tried mood-balancing medications such as SSRIs and cognitive behavioral therapy to treat obsessive-compulsive disorder or major depressive disorder, and those treatments aren't working. You're not alone. Treatment-resistant OCD and depression isn't uncommon.

Matter of fact, it's estimated 40% to 50% of OCD patients are considered treatment resistant. And when those first-line treatments don't work, many explore surgical options.

Dr. Ben Shofty is a neurosurgeon from the Clinical Neurosciences Center at the University of Utah Health and is an expert in surgical treatments for OCD and MDD.

And today, we're going to learn about common surgical treatment options that are providing hope to those with treatment-resistant OCD and depression.

Dr. Shofty, how long does a patient need to be on standard treatments until they're considered treatment resistant?

Dr. Shofty: For a patient to be even considered for therapy, they have to have availed all other therapeutic options, especially the non-invasive ones, which mainly consist of drug therapies, SSRIs, SNRIs, and tricyclic antidepressants, and behavioral therapies like psychotherapy, exposure and response prevention, and cognitive behavioral therapies.

Interviewer: And how long does somebody have to be on the non-invasive types of treatments before they can be considered nonresponsive? Is that a year or longer than that?

Dr. Shofty: Usually, we are looking at patients that have been suffering from the disease at least five years.

Interviewer: Before we head to some of the specifics about the three different treatments, some common questions that might come to mind when treating OCD and MDD with surgical procedures. First of all, in general, are the treatments effective?

Dr. Shofty: The treatments are super effective. Considering the fact that these patients are usually patients that have failed everything else, I think the treatments are life-changing.

Surgical treatment for OCD has been approved by the FDA for more than 10 years, and recently we had a lot of good high-quality data from around the world, in the United States, Europe, and even Australia, that show about 60% to 70% of patients respond to treatment and their disease improves by roughly 40% to 50%, which is a huge change. I mean, these patients can actually go back to living a relatively normal life.

Interviewer: So, I hear those numbers, and in the real world, that is a significant difference.

Dr. Shofty: That's a huge difference, yeah. That's a life-changing difference. Even some of the patients that we do not classify as responders because they only had 30% improvement in their disease metrics, this is a huge improvement even if they're not officially defined as responders.

Interviewer: And surgery can be kind of scary. Do you find that the patients that come in tend to be a little apprehensive about getting surgery for their condition or are they at a point where not so much because they're just looking for any sort of help?

Dr. Shofty: These patients are usually desperate. I mean, they've exhausted every other therapeutic option out there, including a lot of well-based therapies and some experimental therapies, and this is pretty much their last resort.

I also think over the last 10 to 15 years, there has been such a technological improvement in our ability to perform these surgeries safely. And these are quality-of-life surgeries, right? We're trying to improve these patients' quality of life.

So, these are super safe surgeries. Usually, there's a day of recovery inside the hospital, and then the patients go home the following day and go back to their normal lives pretty soon after the surgery.

Interviewer: Then after the procedures, and I realize that for each one it might differ and for each person it probably differs as well, but how long until patients start kind of seeing results?

Dr. Shofty: These are chronic diseases. Patients have been living with them for many years, usually anywhere between 5 and 30, and it takes time for the effect to sort of fully manifest itself. We don't talk about success of therapy at least until six months have gone by. Usually, the maximal effect is witnessed within a year.

Interviewer: When treating OCD and MDD with surgery, generally how do these surgical treatments work?

Dr. Shofty: Our main advancement and the main reason that these therapies are becoming so efficient these days is that we finally understood that it's not a single area of the brain that's not working well, but it's a network, which means that a few, two or maybe more, different areas of the brain are not talking to each other in the way that they should.

And once we've understood that, we can look into a specific patient's disease and the way his brain networks are sort of modulated or altered or working differently, and we can try and target that specific area and that specific place in the brain which is causing this miscommunication.

Once we do that, once we figure that out, the tool that we use doesn't really matter. I mean, we can choose from our sort of toolbox the perfect or the best treatment and sort of tailor the therapy to that individual patient.

Interviewer: That's incredible that you're able to trigger . . . you're able to pinpoint exactly where you need to go and what you need to do in each area.

Dr. Shofty: Yeah. And I think that's the main reason why these therapies are becoming better and better, because our ability to understand the specific patient and the specific patient's disease is becoming better.

Interviewer: And what are some other of the new developments that have allowed this treatment to be so successful?

Dr. Shofty: So, we have a bunch of tools that have become better and better over the last years. One of them is DBS, Deep Brain Stimulation, in which we have newer electrodes and newer devices that can provide smarter and more sophisticated stimulation to the area of the brain that we want to affect.

Interviewer: And Deep Brain Stimulation, I've heard of that before for other conditions.

Dr. Shofty: Yes, it's been around for almost 30 years. It's been used widely for movement disorders such as Parkinson's disease and essential tremor and others, and it's been FDA approved for OCD for more than 10 years.

Interviewer: So, Deep Brain Stimulation might be a procedure that would work for one particular patient. What are other options that are in your toolbox that might work for somebody else?

Dr. Shofty: One of them is creating a lesion or severing a specific bundle of fibers that sometimes causes severe OCD. We can do that today in a minimally invasive approach using laser fibers and under MRI guidance so we know exactly what we're burning and we are just damaging that specific fiber bundle inside the brain.

Interviewer: And with a tool like that, when you're damaging that specific fiber bundle, are there other side effects that might arise out of that?

Dr. Shofty: The reason that this approach was developed is to minimize the side effects, because you are only hitting the sort of damaged part of the brain that you want to affect. And when people used to do that 20 or 30 years ago, they didn't have all these sophisticated tools and they caused more damage than was probably needed. So, today we actually err on the safer side and do less damage.

And then if we have to enlarge the treatment, we can go back in and do it again. It's minimally invasive. Patients go home the next day. There are barely any incisions, so the recovery is super quick.

Interviewer: The third option is Vagus Nerve Stimulation or VNS. How does that work?

Dr. Shofty: So, VNS is an approved therapy for patients with the treatment-resistant depression. It is a peripheral neurostimulator. It connects to the vagus nerve, which then carries the electrical stimulation to the brain.

Interviewer: What is the biggest barrier or reason why somebody doesn't pursue a surgical treatment for their OCD or MDD?

Dr. Shofty: So, I think that there's a knowledge gap with our sort of community providers and community psychiatrists who are not always aware of the modern sort of surgeries and therapies that we can offer these patients. They're also not always aware of the recent advances and publications that have shown that these treatments are safe and highly effective for these specific patients.

Interviewer: Yeah. Somebody like you, this is all you pay attention to, so of course you would know about it.

Dr. Shofty: Yeah, exactly. I mean, medicine is so subspecialized today that it's hard to keep track with all the recent advances. But I think there are a lot of recent advances that have been published that show and support these approaches for these patients.

Interviewer: How should a patient bring this up with their primary physician that they're working with for their OCD or MDD if they're interested in a surgical option and it hasn't been offered?

Dr. Shofty: I think that if you've exhausted all other treatment options, you should bring it up just like that. "I've heard that there's a new psychiatric neurosurgery center at The U and I wanted to consult with them. Is there a chance you can refer me there?"

And we have a quick screening process that allows us to sort of say if the patient is a possible candidate. And for possible candidates, we have a very fast-track assessment process.

The second barrier is to be insurance. I think over the last four or five years, insurance companies have started understanding it's actually cost-effective to approve these surgeries for these patients. And Anthem has actually made a significant policy change and have added DBS for OCD as a medical necessity in their guidelines. So, I think it's easier today to get insurance approval for these procedures.

Interviewer: Well, I'd imagine that there's somebody listening that is very interested in a surgical option at this point given the success rate and given the change in somebody's life. Tell me a brief story as we wrap this up of somebody who came in, had the procedure, what they were like, and then . . . what their life was like, and then had the procedure, and then what their life was like after.

Dr. Shofty: So, we've had an OCD patient who was basically house-ridden for more than three years. Every time he needed to go out of his house and come back, it used to take anywhere between four and six hours going back from the front door to the living room because he had to do so many rituals and so many compulsions. We've operated on him successfully, and six months later, he's back to work. He still has OCD, but he manages it.

One of the good things about these therapies is that they allow patients to respond to medical treatment and to psychological treatments such as exposure and response prevention, which they did not respond to before surgery. So, it's not only the effect of surgery, but it's the effect that it enables them to respond to other types of therapies.

And a lot of our patients have a similar story. They just went back to living a normal life with the disease and not living just under the disease.

Interviewer: It's a situation that no parent ever wants to deal with, but their teen has run away. Once you have located your teen and got them back home, what do you do next? How can you make sure to resolve whatever is going on and why they ran away in the first place?

To help us understand the situation and what steps to take next, we're joined by Amanda McNabb. She is the quality improvement and training manager at the Community Crisis Intervention and Support Services with Huntsman Mental Health Institute.

Amanda, it is a situation that really I think most parents fear sometimes. And when it happens, what do you tell parents, and what is the first step that they should do when they get their kid back?

Amanda: Usually, when a parent is dealing with a situation in which a teenager has run away, one of the things that we really suggest is having another support system with them. So maybe having a mediator, a family friend, somebody who can come in and help keep the emotions that are going on at a minimum so that the conversation can happen about why.

A lot of families will then just say, "Don't do it again. This isn't good. Now you're going to be in trouble." And they don't really focus on what was the reason behind the idea of running away for that teenager.

Interviewer: What are some of the common reasons that they would run away? I mean, I know that every family is different, but with all the amount of people that you interact with, there have got to be some common threads.

Amanda: Absolutely. And those common threads can run from just a teenager who doesn't like the rules in the house and wants to have some extra freedom or things like that. It may be that they're dealing with a lot of pressures and feel like between school and home and friends and everything else that's going on, they just can't handle it and need to get out of the situation.

There may be some concerns about gender identity or feeling accepted for who they are. And that may be another reason that a teenager might leave the home or leave the situation.

The teenager also could be dealing with mental health, depression, anxiety, maybe thoughts about suicide. And the idea of running away is the first step towards "What do I do with my mental health itself?"

Interviewer: So Step 1, get a mediator, get someone in between, calm down some of the, I'm sure, very high-intensity emotions that are happening in that situation. What are some strategies and next steps that we can share with parents who are trying to help identify what is going on with their teen or with their home situation and where can they go next?

Amanda: I think in the beginning, as you said, being able to calm down and really bring those emotions back down to where everybody can actually communicate with one another.

When we're in a high emotional situation, we're not often listening to the other person. We're not having a true conversation. We're always thinking about, "How am I going to respond?" Or with teenagers, it's, "Okay, how am I going to hold this person to consequences for their actions and their behavior?" And instead, we really want to focus more on, "Okay, what is going on in this situation? How can I try to see their perspective?"

With teenagers, and really adults, we each have our own perspective on the situation, which doesn't always match up with somebody else. So we want to focus in on really being able to use those reflective listening skills and those active listening skills to communicate and say, "Tell me more about what's been going on," so that we can come to a positive conclusion and hopefully make things better.

Sometimes with that piece, we really will say to families and parents, "Call the crisis line." We are here not just for suicide or major mental health concerns. We are here for crisis.

And when a family has a teenager who's run away, I define that as a crisis. That is something that is creating a lot of discord and emotional upheaval for a family. And so we're here to try to walk you through those next steps or be able to intervene and say, "Maybe we need to do a mental health assessment on the individuals involved to make sure that everybody is in a safe place to have those conversations."

Interviewer: So with a service like the crisis line with the Huntsman Mental Health Institute, for some people, this might be the first time they are reaching out to a service like this. What can they expect when they call that phone number?

Amanda: When they call, usually, you will get ahold of one of our certified crisis workers who will then just ask, "How can I help you today? What is going on that made you call in?"

And once we've started to define what's happening, what's the situation, what is the actual need in the moment, and sometimes that need is just, "I need to vent. I need to talk about what's going on," or it could be, "I have questions about what resources are available to me," then we can start to collaborate together with the caller and say, "Okay, here's what may be available. Here's what may be an option."

And it doesn't always have to be the parent. It can also be the teenager. The teenager is always welcome to give us a call or use our SafeUT app or anything like that to reach out to one of our crisis workers and say, "I'm struggling with what's going on. I need help." And hopefully, they get a warm reception and are able to feel comfortable talking about some of those issues that maybe they haven't been able to bring up with other people before.

Interviewer: Now, who is the crisis line for and does it cost anything?

Amanda: The crisis line is for anybody and everybody. It is free to the consumer. We are here 24/7. Same with our SafeUT app, which is just a texting way of getting hold of the crisis workers. And it really is for parents, teenagers, anybody who's seeking that extra help.

Interviewer: So for a parent who is dealing with a runaway and it's time to figure out what's going on and heal together, what is the number to get in contact with the crisis line?

Amanda: Parents can reach us at 1-800-273-TALK, or the national number at 988.

Interviewer: Just 988?

Amanda: That's all it is.

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Mitch: Have you been feeling a little off lately or maybe sad for a prolonged amount of time without any obvious cause? I know I feel that sometimes. Could it be depression? And if it is, what are we as guys supposed to do about it?

Depression is one of the most common mental disorders in the U.S. impacting as many as six million men a year. And yet, according to research, men may be more likely to suffer from the severe consequences of depression, like substance abuse and suicide.

This is "Who Cares About Men's Health," where we aim to give you some information, inspiration, and a different interpretation of your health. And today we'll see if we can't shed some light on depression.

I'm Producer Mitch, and I bring a little more than the microphones. And as always, we have Scot, manager of The Scope Radio, and he always brings a healthy dose of BS. Hey, Scot.

Scot: That's right. I'm ready with a healthy dose of healthy BS. I don't know what happened there. My mouth stopped working. All right. Why don't you introduce Troy?

Mitch: And the man who brings the MD, Dr. Troy Madsen.

Troy: Mitch, I'm super excited to talk about depression.

Mitch: I know, right? The most exciting topic. And joining us today is Dr. Scott Langenecker, the clinical neuropsychologist and professor of psychiatry at University of Utah Health.

Dr. Langenecker: Hi.

Mitch: Now, before we get to the professional, I think one of the things that we should probably talk about first is kind of the layperson's understanding of depression, because I think we toss that term around a lot. It's like, "Oh, I'm feeling a little depressed." That seems to come up a lot and I'm not always 100% sure if that's true depression. Scot, when you hear depression, what does it mean to you?

Scot: That's a great question because it comes back to this whole notion of what does it even mean to be happy? I tend to think that my people, if you will, tend to be maybe just a little on the depressed side. Maybe we don't relish in life as much as other people. Maybe we're not as effervescent.

But what is it really? I don't know. Is it a feeling of you just can't go on? Is it a feeling of you can't breathe, like you're dragging your feet in concrete just trying to get things done? Is that depression? So yeah, I'll be curious to find out.

Mitch: Yeah. And what about you, Troy? I wonder if in your practice at the ER and stuff like that, you must have at least a little bit of an understanding of it.

Troy: We do see a lot of patients who come in who are depressed. And certainly, I think all of us have fluctuations in mood and outlook. I think depression in my experience, it's more when it's . . . You get to a point where it's just like this haze, this fog that you're in, and it affects your ability to do your work. It certainly affects your outlook, affects your relationships.

So I see it as certainly a step beyond just a lot of, I think, the fluctuations we might feel in our mood over the course of a day or a week or whatever that might be.

Scot: Or just a little sadness or feeling the blues or something like that.

Troy: Yeah. Exactly. And like you said, Mitch, you might be like, "I just feel depressed today." But yeah, I think it's certainly something beyond that kind of mood changes we might experience.

Mitch: Yeah. And personally, I actually got diagnosed with some depression this last year and have been taking a kind of professional approach to it. But I don't want to bury the lede. I don't want to steal anyone's thunder when talking about depression. So why don't we get to Scott?

Dr. Langenecker, what is depression? And I guess as a follow-up, what is causing that?

Dr. Langenecker: So I want to put it in two big categories to start out with. The first big category is that you all alluded to, that sort of feeling sad for more than just a day, maybe a couple of weeks. So that's one big bucket.

The other big bucket is, "Man, I used to really enjoy hiking or skiing or running or playing basketball, and now it's kind of like blah. It doesn't give me that jazz anymore." And it could be one of those things. It could be one of the other things.

There are another seven symptoms that can be part of it, but those are the two big ones that sort of tip people off. But if you're not looking forward to things coming up in the future, or you look at your schedule for the day and you're like, "This is objectively a good day and I still feel sad," that's probably a tip-off.

Scot: Is it really sadness, though? I mean, how do we even define what sadness is?

Dr. Langenecker: Well, that's a great question because I'm not sure men are allowed to feel sad.

Scot: Oh, okay.

Dr. Langenecker: Can I say that?

Mitch: Only anger.

Troy: Scot, you've never felt it, so you wouldn't know.

Scot: Right. The eternal optimist.

Dr. Langenecker: Sadness isn't a man thing.

Scot: I don't know. Yeah, I think about depression and I don't know that I think about sadness necessarily. Maybe something like overwhelmed with some emotion. Maybe it's overwhelmed with sadness.

Dr. Langenecker: Yeah. So let's talk about the male interpretation of sadness, which is, "I've got people counting on me and I can't cut it. I can't do what I'm supposed to do and I'm letting them down. I feel this pressure and I can't do what I'm supposed to do as a man, supporting my family, supporting my job at work." So it comes across as that. That's one way.

The other way is irritability and anger, which is like, "Ugh, that person just drives me crazy all the time." And maybe it's true. Maybe they are. Or maybe it's just that you're feeling a bit depressed and anything is going to set you off. Those are kind of the two big ones for men.

Troy: It's interesting that you frame it that way too, because I agree. I think a lot of times we think of sadness like just being really weepy and down in the dumps. But to think of it that way in terms of just feeling more irritable and angry and just a sense of inadequacy, that makes a whole lot more sense in terms of, I think, probably how that sadness manifests in us as men.

Dr. Langenecker: Yeah. I would add there's sort of this classic trope about the middle-age crisis for men and getting a new wife and getting a sports car and buying new golf equipment. There's a premise for that that's sort of rooted in depression, which is, "Man, the things that used to really interest me just don't anymore. I feel kind of flat. I feel not into it anymore." Every time you go into that sort of stereotypical midlife crisis mode for men, is that depression? No. But it is some clues, right?

Troy: And you also mentioned it's not just a day. It's not just one day, "I feel irritable today." Maybe I didn't sleep well last night. You're talking about something sustained over weeks to really diagnose depression.

Dr. Langenecker: Yeah. And I should add one more thing. I know you've all talked about the interface between the brain and the body. Sometimes depression comes out, not just in men, but in women too, it comes out in the body. So people are like, "Oh, my back is just driving me crazy. I can't get comfortable, I can't sleep," or, "Man, my knee is just bothering me lately." And it turns out that there's actually a reason for that.

So some of the neurochemical systems that interface between the body and the brain are sending some of those signals both directions. And so it comes out sometimes as pain.

Troy: Yeah, and I will absolutely second that. A very large percentage of people I see in the ER with chronic abdominal pain, back pain, even chest pain, they're clearly underlying emotional health issues, and a lot of that is depression.

So that's a good point of being aware of maybe some of the physical symptoms we're seeing. Certainly not to blow those off as just writing those off without getting those checked out, but it makes sense that a lot of that does relate to depression or mental health.

Mitch: Wow.

Dr. Langenecker: And if you take that analogy a bit further, and this goes back to my upbringing, when you had pain in the olden days, you would go see a chiropractor, like if you have back pain or leg pain or whatever. And what happens in a chiropractor's office? You get a kind, caring individual. They do some manual adjustments. They spend some time with you. It's a powerful human interaction, and it resets some of those neurochemical signals in addition to some of the psychological support that comes with it.

Mitch: So if it's causing trouble in your mood, your behavior, and also in your body, do we know what causes depression?

Dr. Langenecker: We have clues.

Mitch: But no answers. Just clues? Okay.

Dr. Langenecker: We have clues, but no answers. Yeah. So the easiest way to think about it is our brain is really, really sensitive to things that are dangerous to us. And we grew up evolutionarily in a place where it was really a bad idea to not be afraid of a tiger or of a rattlesnake. And it was really a bad idea to sort of go wandering out in the dark at night. And so our brain has adapted over time so that, for many reasons, we would sleep, but also so that we would have a healthy fear of things that could kill us.

Well, it turns out in the United States today, it's a pretty safe place. Part of the evolutionary makeup that we had, too, is that we had to form small groups to protect each other. And so social connectedness was a super huge important part of being healthy and staying alive.

And then the final thing is if we got sick, we needed a system to keep us separated from other people so that we wouldn't necessarily get them sick as well.

All of these things are great if you're running around in prehistoric times with sabretooth tigers and whatever, but it's not super helpful in our environment now. So we have these super-sensitive in-tune systems for detecting danger and stress and so on, and sometimes our system gets over reactive to these triggers in the world.

Sometimes, however, we have experiences which I would put in the broad category of not being fair. And if I had a nickel for every time I said to a patient, "Hey, what happened to you was not your fault, and it wasn't fair, and let's see what we can do about it," I would be a very wealthy man and I wouldn't be talking to you right now.

Mitch: So you're saying that everyone is maybe hardwired to have these kinds of responses? It's not like you are some sort of different. You're not some anomaly if you experience depression.

Dr. Langenecker: This is where I'm at today, after 25 years of studying this. I think that apart from maybe 3% or 4% of humans, we all have the capability of becoming depressed. And I think that's actually an inherent part of being human. I think it's a good part of being a human. And if you don't have those signals working when things go wrong, people probably won't like you very much.

Mitch: You're unlikeable if you can't get depressed? Is that what you're saying?

Dr. Langenecker: You're unlikeable if you don't care about things and don't care about other people. And it turns out if you take that capacity to care and you combine it with bad experiences, a lot of times that's going to end up being maybe not depression, but some sadness, a couple of days of sadness.

So you asked me the question, "What is the cause of depression?" And that's the segue. The segue is a couple of days of sad to more than a couple of days of sad. I use this term professionally. It's perseveration of negative mood. What the heck is that? It means that the negative mood doesn't leave, no matter how hard you try and shake it.

So it brings me back to Charlie Brown with the rain cloud over his head following him around. That is a beautiful example. And I know that Charles Schulz experienced depression because nobody else would draw that unless they experienced depression.

Mitch: And that's interesting that you said that because that was kind of my sign that something was up. In the past, I could maybe go for a jog after I learned to enjoy running, or I could watch a movie and I could pull myself out of a funk if I did these particular activities, eating food I enjoyed, etc. Suddenly, nothing seemed to pull me out of it. And it didn't matter how hard I worked or how many self-help programs I tried or how many books I read, I just could not get out of it. And that's when I knew I had to talk to someone. And eventually, I had to get some medication for it.

Dr. Langenecker: Yeah, that feedback system, right? We have a feedback system from our brain to our body. And you sort of think in depression, that system gets jammed up. It isn't working the way it's supposed to.

I don't know about any of you, I joined the conversation about running late, but I don't like to run. I hate running, but I love how running makes me feel. And if all of the sudden I didn't feel that way after running, it wouldn't take long for me to say, "You know what? I don't want to run anymore." And that's what depression does.

So we mentioned it before. Depression is this sneaky [beep] that takes away the joy from things and then convinces you that that's a good idea. Like, "Oh, no. I shouldn't seek out joy anymore. That's a great idea. I should just sit in my bed."

Troy: And how good are we at actually recognizing that in ourselves? How often do you find people like Mitch who recognize it, get help, versus how often is it others who are really pointing that out, saying, "Hey, you used to really enjoy this. You don't do it anymore. What's up?" I'm curious how that really works.

Dr. Langenecker: It's interesting. I don't mean this in a negative way, but we as humans have a lot going on, right? There's a lot of stuff going on in our heads, lots of stuff going on in our lives. And sometimes we just miss it. We miss it in ourselves. We miss it in other people. And that's not bad on anybody else. That's just the complexity of being a human being.

But sometimes it's absolutely the case that you miss it yourself. Absolutely the case that somebody else is like, "Hey, I notice that you're a bit off. What's going on?" And then of course as a man, our first response is, "Whoa. No, no, no. We're not going there."

Scot: "No, no. Everything's fine."

Dr. Langenecker: "I just rubbed some dirt on it. It's fine."

Mitch: Right. Can we say sneaky [beep], Scot, or is that what . . .

Scot: I don't know.

Mitch: All right.

Scot: Why sneaky [beep]? Why is depression a sneaky [beep]?

Mitch: That's what I was going to say.

Scot: What is the fact that has . . . What's the definition of [beep]?

Dr. Langenecker: Yeah. Unpleasant fellow. Let's use "the sneaky unpleasant fellow."

Scot: Oh, yeah.

Mitch: Okay. I love that.

Scot: I thought it meant something else, I guess. Okay.

Dr. Langenecker: So, in technical speak, we talk about cognitive distortions, like how depression changes the way you view the world. You view the world in more black and white terms, like, "Things are all good or they're all bad," or, "People are out to get me," or, "Things are never going to work out for me." And those cognitive distortions don't really work for a podcast or for actually talking to patients, like real humans. And so I've come to think of depression as this sneaky inner voice.

So you might remember back in the day, long ago in cartoons where they had the devil on your shoulder and the angel on your shoulder. This is kind of the devil on your shoulder saying, "Yeah, things are terrible. They're always going to be terrible. And that person is not going to help you, even if you ask them for help."

And so those cognitive thoughts are happening in the same exact system that does all of your problem-solving. And it doesn't take long to figure out, "Oh, so the same exact system that's doing the problem-solving is also distorting my perceptions of the world." That's the trap. That's the sneakiness of depression.

Scot: It's like a little saboteur.

Dr. Langenecker: It is absolutely a saboteur. And then to add insult to injury, in depression, I will feel ashamed that my brain is doing this to me on top of that.

Scot: Actually, it's like that game. What's that game, Mitch, that brought up the term sus? "It seems sus."

Mitch: Oh, "Among Us."

Scot: "Among Us." Yeah. It's like the little evil person in "Among Us" that pretends to be your friend, pretends to be looking out for you, but really behind the scenes, not doing cool things.

Dr. Langenecker: Yeah. So we come back to the question of "What is depression?" Depression is your own brain convincing you that things that are good for you aren't good for you.

Mitch: That resonates so much with me. I was actually talking to my therapist the other day. I've been in a bit of a depressive episode. And when I was chit-chatting, it was just like . . . He's like, "You know what you need to do to get better." And I'm like, "I know. I need to start eating better, I need to get out, I need to do the things that I enjoy more, remind myself I enjoy them. I need to be talking to people."

And he's like, "Even if you don't like doing it right now, that's just your depression telling you, 'No. Don't work out. No, don't go talk to these people because they hate you,' or whatever. Just power through it. Ignore them. It might be unpleasant, but you've got to start doing those types of things if you're going to get out of the depression cycle."

And I think that's kind of what I want to ask next. What do you do? How do you fight back against this saboteur of depression?

Dr. Langenecker: I'm glad you brought that up, Mitch, because there's another piece to this. So you take this maleness of "I don't need help," and then you take this sort of cultural belief that we're doing the Horatio Alger thing and just pulling ourselves up by our bootstraps. And then you take this idea of positive psychology, which is literally rub some dirt on it or rub the dirt off of it. I don't know what it might be. And for somebody who's experiencing depression, that's basically telling them, "You're an idiot. You can't figure it out. You should have figured it out a long time ago. Why are you such a moron?"

And I'm using really strong language here because that's the saboteur. The saboteur can take really well-meaning, "Hey, maybe you could try this," or often, "You should do this," and it comes across as, "I'm incompetent, and I'm making a big deal out of this, and I should just get over it."

So part of the work with a therapist, honestly and truly, is getting folks to realize that they deserve better and to believe that they deserve better and to do things in the world to actually experience the better. That's how we beat the saboteur.

Mitch: That's interesting, because on another episode we kind of talked a little bit about the first couple of mental health workers I worked with. I was suffering from depression and that was the very same thing I felt. When that first person was like, "Oh, yeah, have you tried gratitude journaling?" the first thing I thought was, "I've tried it. It's obviously not working for me, doc. You've got to help me here. I'm not going to open up the journal again. Things are obviously terrible."

And I think looking back on that, he was probably giving decent advice and good advice. I just was not in the mood to hear it.

Dr. Langenecker: And that's why I use the analogy of a journey with some really comfortable shoes because it's not just the what, it's the when. And there's a phenomenon in depression, the waxing and waiting of depression, where as a therapist, I wait for windows of opportunity. I don't force windows of opportunity. And that has taken years to hone that skill, because if I force it at the wrong time, I'm going to be breaching some of that trust that I worked so hard to build with my client.

Mitch: So to kind of wrap up this discussion on depression, Scott, it sounds like depression is when you are feeling out of sorts or sad for more than one day, things that you used to enjoy aren't giving you that spark of joy that they used to. At what point should someone . . . what is a sign, a red flag that they should probably go talk to someone or they should probably seek some sort of treatment in one way or another? And what can they expect on those first steps of their mental health journey?

Dr. Langenecker: So to come back to that point, having the sadness or lack of joy for . . . Technically, we use the term two weeks or more as sort of the breakpoint. That is not a magical number. That is just a number that we've come up with over time. It could be more than five days, it could be more than three weeks, but just sort of this idea that something is off.

And then if it starts to mess with your sense of who you are as a person and what you deserve in the world, that's the point at which you say, "You know what? I don't have to fight alone. There are really talented people who are out there ready to help me."

Mitch: I love it. And what can they kind of expect on their first couple of steps into getting help?

Dr. Langenecker: I think the main thing is don't rush it, like we were talking about before. Don't feel like you have to rush this thing. We get into this mindset of, "Oh, I can take my car in for a tune-up." A brain tune-up is much more complicated than a car tune-up. It might take a couple of months. It might take longer. Be comfortable with the idea that you are investing in you. You are investing in you deserving a better life.

Mitch: Scott, thank you so much for joining us, and thank you for caring about men's health.

Dr. Langenecker: Thank you.

Interviewer: You've noticed a change in your teenager's mood. They're angry, moody, defiant, irritable, and in addition, their school performance or maybe interest in other activity is significantly decreased. You're worried about depression. Is it okay to talk to them about it, or could it cause more harm than good?

Dr. Thomas Conover is a psychologist at University of Utah Health, and what is your advice for parents about how to talk to their teens about these tough topics? Or should they even talk to them about them?

Dr. Conover: Communication is a real key. It certainly is protective and helpful for parents to communicate and inquire with their teen as to what's going on and how they're feeling. And that's something that I think most parents strive for but may struggle with. How do I talk to my teen? What do I talk to my teen about? Is it okay to ask? I would advance to say that it's always okay to ask your child about how they're doing. You seem really sad lately. Is there something bothering you? Is there any way I can help?

Interviewer: No. I mean you probably have to dig a little bit sometimes, huh?

Dr. Conover: You may. I think that there's value in setting an example and leaving the door open by saying those two things. In terms of setting an example, certainly communicating openly oneself is important. Right? So I've talked about various areas of function that a parent might look at for a teen child and use to try to evaluate how serious a problem that they're suspecting maybe. But a parent can show that those things are important themself. Right? A parent can demonstrate that being engage with social activity and self-care and physical activity, you know, which boosts mood, all of those things are important. So a parent may set the stage in their own family by doing those things.

It's always okay to ask your child about how you're they're doing. And even though a lot of times teens may seem outwardly like they don't want someone to ask, I think most of the time people who are struggling even in a small way do want someone to ask. I think it's helpful not to badger. I think if you're met with that initial no on a first inquiry, it's good for a parent to perhaps say, "Well, okay. You know, I hear that you're saying that there's nothing about it that you want to talk about. But just know that I'd be happy to talk to you if you do . . . if you change your mind about that, if you do want to talk about."

I think that's a tough one. It's a tough balance to strike, because I think if a parent is a concerned at all about their child and they try to make that initial ask, first off that's a hard thing to do. You know, you might be thinking about it all day or all week and then, finally on Friday you say, "Oh, we're sitting at dinner and my kid's actually home with me. I'm going to ask." And then, the first thing that they snap back with this, "No. Everything's fine." And the parent might feel kind of rejected by that and, you know, they might respond by shutting down. Right? Going like, "Oh, well, okay. I guess I shouldn't have asked."

I wouldn't advocate for that black and white of a response, nor would I advocate for a parent then saying, "Well, no, I know something must be wrong. I've been watching you all this time, and you just aren't acting yourself. You need to talk to me right now." You know, in most cases, that's not going to be the best approach either. It's, I think, always appropriate to ask and it's always appropriate to maybe give a little space and a little time for the teen to be able to absorb the question and respond. Now, that would be with the exception of a true emergency, and those emergencies do include threats or acts of self-harm or threats or acts of a suicidal nature or serious aggression.

Interviewer: Are you concerned that your teen might be suffering from depression? Now, sometimes it can be difficult to tell the difference between moodiness and actual depression, and that moodiness can be common in a lot of teens.

But psychologist Dr. Thomas Conover says you should look at how your children are doing in what he refers to as key life areas. That's school, extracurricular activities, social, and family life.

Dr. Conover, let's just start with school. Why is school performance one of the clues that you use when evaluating children for depression?

Dr. Conover: For teens, school is their primary area of function. It's, in my mind, equivalent to holding down a job or a career for an adult, right? And so if an adult is still functioning in their primary vocation, then that's a good sign. Same way for a teenager. If he or she is still doing well in school and not seeing a decrement there, then whatever is going on with the teen, you've got some reassurance that things haven't gone completely south.

Interviewer: What about extracurricular activities? Some kids just aren't into school, or don't necessarily perform well in school.

Dr. Conover: Well, I look for their performance in school with comparison to earlier performance too. So if you have a kid who was somewhat of an indifferent student and just wasn't that academically inclined throughout their school life, kind of a solid B/C student, then that's what I would be looking for the child to be doing going forward. So I'm not concerned if there's sort of indifferent performance when that's been the norm.

It's really looking at, "Has that gone downhill?" Do you have a child who normally got straight As and is now getting Bs and Cs, or a child who normally gets Bs and Cs who is now failing or having incompletes? That would be more concerning in terms of school performance.

And for those youths . . . let's say you have a child who's an average student and maintaining that performance, but who is an avid athlete, plays a sport year-round, and is withdrawing from that. That could be a concern as well. So looking at function in the academic realm is important, but there are other areas of function too, right?

So other activities are very important to look at. Social function. A normally developing or typically developing teen is a very social creature. It's a time of life where you're learning how to be independent, and you're transitioning in typical development from being reliant on your family as a primary source of your activities and values to your peer group, which in my mind and experience serves as somewhat of a transition to being fully independent. Having your own ideas about things, your own values, your own priorities for your activities.

So, in that vein, your typically developing 15-year-old is going to really want to be out there and socializing with peers. A lot of times, nowadays, that does take place over cellphones, social media, and the like. And so it's important to take that into account, that just because a teen isn't going out all the time doesn't mean that they're not socially engaged.

But a parent can reasonably expect that their teen is going to be interested in what's going on out there with their peers. And if they're more withdrawn or less interested in that than they used to be, that's a concern.

Then there's also family function, and it is normal and expectable to have a teen be less interested or less enthusiastic about certain family activities than he or she used to be. That is normal and expectable.

Then I would go back to the idea of, "Well, just how pervasive and intense is it?" Do you have a teen who says, "I don't want to go to family dinner at grandma's this Sunday. My friends are going out. I want to meet up with them," but who ultimately you can cajole and negotiate and get the teen to do it? Or do you have a teen who has a big blowup over that and ends up leaving the house and you don't know where they went? I'm giving fairly stark examples, but the gray area in between can be evaluated.

I haven't mentioned the threat of self-harm, or aggression, or worse, suicide. That would be an obvious red flag. If inquiry into a teen's mood or a parent making a request or demand of the teen leads to any sort of threats or acts of self-harm or aggression, then that's something that a parent would want to seek help for urgently.

Suicide is one of those topics no one wants to talk about, but something that needs to be discussed. This is our topic today on The Scope.

Recently, a longtime family friend's daughter, who my kids have grown up with since they were really little, whom we have known since before our 12 year old was even born, acted on an impulse and took her own life. This podcast is dedicated to her. Her parents know I'm doing this podcast in her honor. During her services, her parents spoke about how important it is to bring awareness to the reality of suicide in teens, to talk about it, to talk to your kids about how they can come to you if they're having thoughts of self-harm, that there might not always be the warning signs that people tell you to look for.

With teens, their brains are not yet fully developed in terms of executive function skills. So they often can't see that while things may be bad right now, there is hope. And often, in time, things will improve. This is true so much this year with the pandemic. Our teens are not able to do normal teenager things like school functions, dances, hanging out with friends, having their first boyfriend or girlfriend. They have been cut off from interactions outside their families. Teens can only see what is happening here and now. And in their minds, it feels like things will never be the same again.

Unfortunately, they're probably right. Things will most likely never go back to the way that they had been. However, there is hope, hope that we are better able to understand COVID and hope that we will be able to bring an end to the pandemic. Hope that within the next year, people can start returning to what we consider normal life.

Knowing someone who has completed suicide will rock you to your core. Sometimes there are signs like sadness, wanting to sleep more, or stay away from others more than teens normally do, grades falling and your teen not really caring about school. Sometimes there is a history of mental illness or self-harm, and it gets the better of them. And sometimes, a teen will struggle in silence. They will appear happy and social on the outside, but be suffering within, until one day that wave of suffering overpowers them, and they act on their immediate feelings with fatal results.

The more I have spoken to teens and parents of teens, the more the subject of negative thoughts seems to come up. More and more teens are having these thoughts. More and more teens are doing self-harm, like cutting or attempting overdoses. I have about a patient a week lately, where I am having this conversation with them. It's real, it's serious. Teens need to know that we are there for them and that they can come to us, that they have options for help. No, we can't make everything go back to the way it was. No, we can't take their feelings away from them. But we can help them work through their feelings, give them options that are safe, and help them to understand that they aren't alone.

We see you, we hear you. You are beautiful and special, and you are loved.