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Depression (transcript)
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(Narrator)    This week on Second Opinion, psychiatrist, Dr. Eric Caine.
(Dr. Caine)    I know that depression is the leading cause of disability in women in the United States.

(Narrator)    Psychologist, Dr. Judith Beck along with special guest, Mary Jo Codey.

(Mary Jo Codey)    You can hide depression.

(Narrator)    Counselor Sheila Briody joins panel regular Dr. Lou Papa, civilian, (Elissa) Orlando, and host, Dr. Peter Salgo.

(Dr. Salgo)    Isn't the lack of diagnosis, not Lou's fault, it's not the system's fault, it is Ginny's fault to some degree.

(Narrator)    In a revealing look at the depressive illness.

(Narrator)    Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent Blue Plans.  Committed to better knowledge leading to better and more affordable healthcare for consumers.

(Dr. Salgo)    Welcome to Second Opinion where each week we solve a real medical mystery.  When we close this case file a half an hour from now, you will not only know the outcome of this week's case you will be better able to take charge of your own healthcare.  I am your host, Dr. Peter Salgo.  Our case file today contains a story of Ginny.  You have already met the healthcare team assembled right here to tackle this case.  Some are doctors and some are not.  No one on the panel knows the case, except our resident civilian Elissa Orlando.  How are you Elissa?

(Elissa)    Great, thank you.

(Dr. Salgo)    Good to see you again.  Let's get right to the case shall we.  We are going to talk about Ginny, as I said.  She is a 41-year-old chemist for a major corporation.  She is in her doctor's office for the second time in eight weeks.  Eight weeks ago, Lou, she came in with stomach symptoms, heartburn, nausea, feelings of bloating it says here.  Her primary care doctor recommended that she go on some over-the-county antacids and H2 blockers.  I think they gave her Pepcid AC.  Given the generally-Ginny has been pretty healthy Lou, does it sound reasonable to you?

(Dr. Papa)    That's a reasonable way to start.  She is back though.

(Dr. Salgo)    She is back.

(Dr. Papa)    That's a reasonable way to start.  She is back, and hasn't had any improvement in her symptoms.

(Dr. Salgo)    Matter of fact, the same complaints.  The antacid, she says, has had no effect.  "Thanks, but I am not taking it."  Now she is not sleeping.  Another complaint has been added.  She has got headaches.  She said she is tired all the time.

(Dr. Papa)    The symptoms have started to broaden out from where the original complaints were in the gastrointestinal tract to other symptoms, and that is unusual.  There are conditions that can do that.  Once I start to hear that people are fatigued and having headaches, I want to investigate a little bit more about her sleeping and her energy level and what is happening day-to-day for her. 

(Dr. Salgo)    Well, what would you like me to tell you?

(Dr. Papa)    How is work?  How is the family?

(Dr. Salgo)    Work is terrible.  She has been moved from a job where she was using her chemistry degree, and her company has been downsized.  She is basically in a supervisory position, somewhat decreased pay.

(Dr. Papa)    I would also want to know about is she doing the things that she normally enjoys doing?

(Dr. Salgo)    Not many.  She has been busy, and I will tell you something else.  It says here that when she was talking to her doctor about the recurrence of all of these symptoms, she lapsed into another topic altogether.  That topic was taking care of her mom.  Her mom had coronary artery bypass surgery, and while she was talking about this, she broke down and began to sob.

(Dr. Papa)    I am getting more and more concerned about a depressive illness.  I am not sure if I can say it is depression yet.  I need to get more information.

(Dr. Caine)    As soon as I start to think about psychiatric symptoms, I kind of want to know a lot more about the person.

(Elissa)    Wait.  We are already into psychiatric symptoms.  Here is somebody with a lot going on.  Her company is downsizing.  She has been taking care of her mother.  Those things alone might give me heartburn. 

(Dr. Beck)    I want to know what her mood has been like.

(Dr. Salgo)    She is sad.  She says she has been sad.

(Dr. Beck)    And has she been feeling worthless, lack of failure, is she feeling guilty, hopeless?

(Dr. Salgo)    One of the phrases she used when giving a history was she thinks first no one would notice if she were gone.  The world might be better if she weren't in it.

(Dr. Beck)    Right.

(Dr. Salgo)    Does that ring any bells?

(Dr. Beck)    Oh, it is typical of depressive kinds of thoughts, but we have to find out how often she has these, how much she believes them, how much they affect her mood, how they affect her behavior.

(Sheila)    Yeah, but I want to know more about her context.  So, you have told me a couple of-

(Dr. Salgo)    What do you mean by context?

(Sheila)    Well, you have told me about her job.  You have told me about her mom.  What about her personal life?  Does she have anything that brings her joy?  Did any of the things that used to bring her joy still bring her any kind of satisfaction?

(Mary Jo)    I think that you guys are analyzing someone to death.

(Dr. Salgo)    What does that mean?

(Mary Jo)    Being analyzed to death is everybody is going back and forth with, "Well, maybe this happened and maybe that happened."  Maybe she just got depressed.

(Dr. Salgo)    You have been sitting here listening to all of this.  You have had a significant depressive episode.  Can you tell us about it?

(Mary Jo)    I didn't need any help knowing that I was depressed, because I couldn't change my clothes.  I also have been depressed in my life where I didn't need to find out why.  It just happened.  I don't think that everybody that gets depressed has a reason, because I know I-

(Dr. Salgo)    Oh, absolutely.

(Mary Jo)    I fell into a deep depression with no reason.  I had reasons in my life to be depressed when I wasn't depressed.

(Dr. Salgo)    Tell me a little bit about what that was like.  Share that with us.

(Mary Jo)    When I was depressed?

(Dr. Salgo)    Uh-huh.  How did it start?  What did it feel like?

(Mary Jo)    I would just like would go to put my makeup on in the morning and think, "Gee, I am kind of ugly."  Then everyday would be like, "I am kind of fat.  I am ugly and I am fat, and I am not that bright."  Then it was like, "Why bother going out into the world.  You have nothing to offer."

(Dr. Salgo)    When was all this going on?  How old were you?

(Mary Jo)    About two years ago.

(Dr. Salgo)    You had trouble when you had children as well didn't you?

(Mary Jo)    I had postpartum depression twice, which is not unusual.  Postpartum depression happens to people that have a history of depression.

(Dr. Caine)    This history I think it is really important, because that's going to potentially be one of the tip offs here, and that going back now and trying to understand whether there was a depression ever in the past or episodes of real despondency when it didn't make sense.

(Mary Jo)    Right.

(Dr. Caine)    You know, when a lightening bolt out of the blue or something, it felt like, "I shouldn't be like this.  Things are going great."

(Dr. Salgo)    Let me stop right here and ask you, if you can succinctly and maybe this is impossible, to define depression.

(Dr. Beck)    We make the diagnosis of depression much as, you know, some throat doctor makes the diagnosis of an earache on the basis of symptoms, how many they have, how long they have lasted, and how severe they are.

(Dr. Caine)    For two weeks you have had either a profound change in mood or a profound loss of interest.  One of the questions I am starting to wonder about is whether she was downgraded in her job because she was depressed all along.  The fact was that she wasn't doing very well, and I am not sure which is the chicken and which is the egg.  Until I get to know her better, you know, it may be that in fact this has been, as I said, smoldering a little fire for a long time.

(Dr. Salgo)    She has been taking sick days, and that has been noted in her employment record.

(Dr. Caine)    Well, that could certainly be that maybe she was depressed or has this problem for quite awhile. 

(Dr. Salgo)    How big a problem is depression in America?  What percent of people have depression?

(Dr. Caine)    Lifetime people are talking about major depression of like 1 in 5.

(Dr. Salgo)    Twenty percent.  That is enormous.

(Dr. Caine)    Like across the course of life.

(Dr. Salgo)    Tell me a little bit more about your story, because I think it is dramatic.  When you had your first child and you had a postpartum depression in a setting, I guess, where you were prone to depression.  What were you doing?

(Mary Jo)    No one ever asked me in the hospital if I was prone to depression, because people don't have the time for depression.  I couldn't wait to have my son.  When I woke up in labor, I was happy.  I had my first pain, and I was grateful, because I knew I was going to have a baby within about 24 hours.  When he was born, I didn't want to hold him.  I got it that fast.  That's why I can't see analyzing everything to death, because it happened to me in a minute.

(Sheila)    But the thing is with this woman we don't know some of the past history of it.  Like some of the things you said so far I would question about grief, the number of changes in her life and her hopes and dreams as a chemist.  And then the sickness. 

(Dr. Salgo)    Did you know something was wrong?  Did you have enough insight into yourself to know that something was wrong with you?

(Mary Jo)    No, because it didn't match reality.  The reality was I had a wonderful, healthy, beautiful baby boy that I wanted my whole life.  I am a teacher.  I couldn't wait.  The reality was I didn't want to answer the phone.  I didn't want to see the baby.  I didn't want to talk to anybody.  I didn't want to see my mother.  I didn't want to see my sisters.  And it didn't make any sense to me.  That's why I am not a reality-based depression person, because mine never matched my reality.

(Dr. Beck)    For some people it does, and some people it doesn't.

(Dr. Papa)    Your situation is very helpful from a primary care point of view, because when I hear something like that, these things are happening, life is great.  I have no-that's where the big guilt part comes in.  Life is great.  Why do I feel this way?

(Dr. Salgo)    There was a moment, several moments when you thought actually about killing your child.

(Mary Jo)    Right.  That's called an intrusive thought.  It is very common in postpartum depressed woman.  It is not an action, and it is not a desire to do the action.  It is an intrusive terrifying thought.  These thoughts didn't happen when I was depressed in the beginning.  The depression grew deeper.  When the depression got deeper, I would have scary thoughts.  Like I would be giving Kevin a bath, and I would be too depressed to go downstairs and get a plastic cup.  There would be a glass, and I would start to rinse his hair with the glass and think, "What if I cut his throat?"  They are terrifying, debilitating, horrifying thoughts.

(Elissa)    Were people around you noticing this?

(Mary Jo)    No, because you can hide depression by laughing at a joke.  If you laugh at a joke, and depression goes right out the window.

(Dr. Caine)    That actually brings up one of the issues with our patient, because we don't know whether she has always been forthright about this or whether that she has been trying to hide it.  You know, here is a person she has got a job, she has got to take care of Mom, and, you know, it may well be that she has been trying to pull it together.  So, depression is often this, you know, we are saying, "You know, you don't always get it."  Well, it is often missed because people don't tell other people.

(Mary Jo)    My parents didn't have a clue.  My sister didn't have a clue.  I was so ashamed of being depressed after having Kevin.  I put him in his Santa suit at Christmas time, and they thought everything was fine.  In January, my husband calls up and says, "She is going to a psychiatric hospital.  She has been depressed for four months."  They couldn't believe it.  You can hide depression.

(Dr. Papa)    Patients will come in for their pain, or they will come in to have their blood pressure checked, and unless something triggers that in the patient's mind and the doc's mind, you know, an upset stomach by the way of headaches and, "I am tired, and I am not sleeping well, and I cry a lot."  That's something that kind of triggers it.  You can sometimes kind of get an idea on a routine physical examination where you can ask questions about.

(Elissa)    Are you always thinking about it? 

(Dr. Papa)    Of course I do, because it is so prevalent.

(Dr. Caine)    The primary care docs don't screen for depression, for example, the way they screen for blood pressure or cholesterol.

(Dr. Beck)    But they ought to.

(Dr. Caine)    They ought to, exactly.

(Dr. Beck)    But they ought to.  They ought to use the two rule-out questions that you just said, "Have you had kind of a sad, down, depressed mood everyday, almost everyday for the last few weeks, and/or have you lost interest in almost all of your activities almost everyday all day?"

(Mary Jo)    No fault of his.  I found as a depressed patients doctors don't want to hear if you are depressed.  It takes too much time.

(Dr. Papa)    What it is let me tell you something-

(Sheila)    You have no time.

(Dr. Papa)    I have got you that wants to ask me two questions, I have the urologist that has two questions, and we have the urinary incontinence person that has two questions.  I have a multitude of different specialists that want me to ask if they can talk to me.

(Dr. Caine)    I am going to argue with you on this, because I know that depression is the leading cause of disability of women in the United States.  The leading cause of disability of women in economically developed countries.  By 2020 it is going to be the leading cause of disability in the world.  It is also clear that depression is associated with really big bad outcomes like loss of jobs, loss of life, loss of ability to take care of family.

(Dr. Salgo)    Right now I would like to sum up a few key things to remember here before we move on.  I think it is really important to remember as we have been pointing out, I guess, over and over again that depression is a serious health condition, which is under-recognized.  It is not a normal state of being.  When you are depressed, you are at risk up to and including the risk of death. 

(Elissa)    Can I ask one more question, too, about you just mentioned it is a serious health problem.  It is not a normal state of being.  It sounds to me almost like a medical diagnosis.  So, when we talk about testing and screening, isn't there some other test?  Can't you find out from a blood test or some other kind of medical test whether or not somebody is predisposed or is depressed?

(Dr. Papa)    You have to rely on their listening skills and communication skills of the patients.  It is a wonderful diagnosis in primary care.  There is no test.  You have to just be really good at listening. 

(Dr. Salgo)    Here we have Ginny.  Let's go back to Ginny.  Remember Ginny?  We are still curious about Ginny.  She is the woman that we want to know more about her.  Ginny came to see Lou, and she didn't say, "I am sad."  She didn't say, "I am depressed."  She came back eight weeks later, and she broke down and cried involuntarily, which is the first time she seems to have acknowledged her mood at all.  Isn't the lack of diagnosis not Lou's fault, not the symptom's fault, Ginny's fault to some degree? 

(Dr. Caine)    I don't know where the word fault comes from.  That's a setup, because that starts to get at the question of are you blaming the person for being depressed.  Is depression a weakness?  Is it a moral flaw?  Is it something in your character?  You are saying you are feeling guilty about-

(Mary Jo)    I think when I was depressed, I was very, very ashamed. 

(Dr. Caine)    Right.

(Mary Jo)    If Ginny is hiding her depression, it could be from her shame.

(Dr. Salgo)    Ginny's doctor tells her she is depressed, okay.  Then she says to her doctor, and he writes it down.  She doesn't want her doctor to tell anyone else.  It is a medical diagnosis, but she doesn't want anyone to know.  Does that sound familiar?

(Mary Jo)    I went to a pharmacy four towns away from the town that I went to when I got an antidepressant to fill.

(Dr. Salgo)    Four towns away.

(Mary Jo)    I wanted nobody to know who I was.  It has nothing to do with politics.  It didn't matter.  As a human being, I didn't want anyone to know that I was depressed. 

(Dr. Caine)    How come?

(Mary Jo)    Because I felt like I was a failure.  I was like, "How could I be-"  When I first found out that I was depressed, the very first time I was depressed, I was like I married who I wanted to marry.  I got a college education and a career I enjoyed.  I don't have a money problem.  I felt like there is plenty of people who suffer more than I ever suffered, and they should be depressed.

(Dr. Beck)    That's exactly the problem.  It is because people in normal speaking say, "I am depressed."  The way that most people use the word is extremely different from clinical depression.

(Mary Jo)    They just throw the word around.

(Dr. Salgo)    Let me tell you a little bit more, because Lou wanted a workup.  You wanted a medical workup to rule out other potential causes of mood shift or not feeling well.  That's what she got.  All of her blood work is normal.  There is no sign of serious illness on any studies they did.  She is not menopausal.  Let me simply say here that all of the chemical, biochemical, physical exam workup, anything we could look for, everything that Lou could order is normal, and yet she is depressed.  What is going on in her brain at the biochemical level?  Do we know?

(Dr. Caine)    The biochemical version gets redefined at regular intervals, because there is probably thousands of neurochemicals in the brain.  People are very entranced still with the neurochemical serotonin.  They are entranced with another one called norepinephrine.  They talk about how these things are modulated.

(Elissa)    It sounds like what you are saying is that there are physical things that happen in the body and the brain.

(Dr. Caine)    Right.

(Elissa)    When depression hits.

(Dr. Caine)    Some of my depressed patients have said, "I feel like I have the worst case of the flu I have ever had.  I ache.  Not only do I have a hard time getting out of bed in the morning, but I feel just like lead." 

(Dr. Salgo)    You are in the public eye.  Your husband is a prominent politician.  You have come out about a number of health problems in your life, which brings me to an interesting question.  If we have accepted depression as a medical issue.  You have had other medical problems, including breast cancer.  You had no problem, I guess, coming out about that and talking about it.  What is it about the depressive medical problem that's so different, the stigma?  Why didn't you want to come out about that so quickly?

(Mary Jo)    I have a lot of things in my life.  I have a lot of good things, and to be depressed just makes me feel guilty.  Breast cancer was something that happened to me.  Depression feels like something I did to myself.

(Dr. Salgo)    Oh, which brings us back to the question I asked before is it Ginny's fault?  You seem to at least, at first, have thought it might be, might be your fault.

(Mary Jo)    Yes.  I thought it was my fault, and then I thought it was my mother's fault.  I was trying to figure out whose fault was this.

(Dr. Caine)    It is not just the person.  For hundreds of years it was the social value system, too, that people who killed themselves or people who had depression, or people who couldn't be themselves that somehow there was something wrong with that person as a person.

(Mary Jo)    Well, I think people that get depressed have to start opening their mouth, which is why I do.  I think when you are down you have to speak up. 

(Dr. Salgo)    All right, let's pause for a moment.  I want to sum up a few key things that we have discussed in this session before we move forward.  First of all, depression can be a neurochemical disease causing major personal disability.  In fact, it is the number two cause of disability in the world.  That's really important.  I want to go on a little bit further with this.  Ginny is understanding that her diagnosis may be depression.  She is getting more comfortable with this.  She tells her pastoral counselor at her church that she has agreed to let the doctor treat her.  What do you think is the most likely treatment she is going to get?

(Sheila)    My fear would be that she is going to get pills.

(Dr. Salgo)    Why is that a fear?

(Sheila)    I don't think that is the first line, because as a pastoral counselor, I want to look at the context.  There are ways that cognitive behavioral ways that I can learn to change some things in my life.  I can learn to change my expectations.  I can build a support network that can help me.  Now, I will leave it to the medical people to say when the biochemical thing kicks in.  There are some stages early on-

(Dr. Caine)    We might disagree about what the first line is.  We might disagree on the basis of how severe the depression is.

(Dr. Salgo)    When she said she didn't want to get medication, I thought I caught a glimpse on your face of, "You go.  That's right."

(Dr. Beck)    There is a little of each.  I think it really should be a collateral decision between the patient and the doctor.  The doctor needs to hear these symptoms, needs to make a diagnosis, needs to see whether the patient agrees with that, what she doesn't agree about that, and then layout the treatment options.  The latest research shows, for example, that a form of psychotherapy called cognitive behavior therapy is equally effective as medication for the mild, moderate, and severe depression.

(Dr. Salgo)    What the heck is that?

(Dr. Beck)    Well, it is a form of psychotherapy that was developed in the 1960s, and it is probably the most highly researched form of psychotherapy that there is.  Not only in this country, but really in the world.  There has been about 350 studies that show it is effective for a whole range of psychiatric disorders, especially for depression.  It is based on the notion that when people are in psychological distress, their thinking is just not very clear.  They are just not seeing the world and themselves very accurately.  Half of the therapy is helping them learn some new tools so they can change their behavior and their thinking.

(Dr. Salgo)    How about this for tools.  I turn on my television, and everyday I see the same commercial, "You may be sad.  We can make you happier.  Look at this where you were in this drab house, but now that you have taken our pill-"

(Dr. Caine)    You are pressing some of our buttons.  It is really striking that some of my colleagues have done research and published this.  If you look in primary care settings, I am not saying your primary care setting, of course.  If you look in primary care settings, what you find often is that someone comes in and says, "Doc, I am depressed," then they will get a pill. 

(Dr. Salgo)    What do the pills do?  If they make you less depressed, how do they do it?

(Dr. Caine)    Well, the pills change brain nerve chemistry.  There is no question about it.

(Dr. Salgo)    But you told me brain neurochemistry and depression was abnormal, so if the pills change it, why not use it.

(Dr. Caine)    Well, because not every depression is related to that. 

(Dr. Salgo)    Well, Ginny is put on a drug.  I will tell you what Ginny is put on.  She is put on an SSRI.  What's that?

(Dr. Caine)    That's a selective serotonin reuptake inhibitor.

(Dr. Salgo)    What's that?

(Dr. Caine)    It is a particular type of drug that given what we know about brain neurochemistry, preferentially gets more of the neurochemical serotonin in the brain.  I want to finish up one point before we get through this.  Just because we put people on pills, doesn't mean those pills are harm free.  Pills have side effects.  And so every time you put someone on a pill, what you are asking is is the benefit substantially greater than the risk. 

(Dr. Salgo)    All right.  Let me set it up then.  She is put on an SSRI.  She is put on an antidepressant pill.  We know that depression has side effects up to and including death.  Pills have side effects.  Is everybody happy she is on an SSRI?  Are you?

(Sheila)    It depends on how extreme her depression is.  I think there are other ways you can work with this.

(Dr. Salgo)    Are you happy she is on an SSRI knowing what you know?

(Dr. Beck)    If it works, and if it doesn't have undue side effects, then I think that's great.  However, being on medication doesn't mean that she won't get depressed another time in her life.  So, I would feel more comfortable if she is going to be on medication if she could also see a psychotherapist to learn skills to prevent depression in the future.

(Mary Jo)    My depression went away pretty quickly after I was on the right medication.  Like two weeks I was fine.  Nothing changed with how I dealt with anything.  I took the pills and I was better.

(Dr. Salgo)    The pills worked as far as you are concerned.

(Mary Jo)    They did.

(Dr. Salgo)    Is the rest of this just hogwash?  Just going to-

(Mary Jo)    For me it is.

(Dr. Salgo)    Going to talking therapy-

(Mary Jo)    For me it is.  I took the pill and it worked.

(Dr. Beck)    What about the shame in the family?  What about the part that had to stay hidden?

(Mary Jo)    The shame was horrendous.  I went for shock therapy, and I couldn't even look at the doctor in the face.

(Dr. Beck)    Shock therapy.

(Dr. Salgo)    I don't want that to just slip by.  Shock treatment.

(Mary Jo)    I had severe depression.  I went for shock therapy, and the shame-people were like, "Oh, my God, shock therapy."  Shock therapy was nothing compared to the pain of depression.  The pain of depression is horrendous.

(Dr. Salgo)    Tell me about it.  What does it feel like?

(Mary Jo)    Like I was thinking what kind of loser has to go for shock therapy.  That's the bottom of the barrel as far as I was concerned.

(Dr. Caine)    Did you feel it in your body?

(Mary Jo)    Did I feel shock therapy in-

(Dr. Caine)    No, no, the depression?

(Mary Jo)    I felt-I couldn't even talk.  Remember when we were talking about those slow motor coordination and the psychological implications.  I couldn't even-I was talking like this.  I was so depressed.  They signed me up for shock therapy, which I couldn't have cared less, because I didn't care about my life. 

(Dr. Caine)    Did it work for you?

(Mary Jo)    Did it work?

(Dr. Caine)    Yeah.

(Dr. Beck)    Shock therapy.

(Mary Jo)    Not really.  It didn't work, but I have seen it, because I have been in psychiatric hospitals, and I have seen patients turn around on shock therapy.

(Dr. Caine)    It is interesting, because, of course, statistically it is the most effective treatment.

(Elissa)    You are kidding.  I didn't even know they did it anymore.

(Dr. Caine)    Oh, yeah, but it is not Jack Nicholson in One Flew Over the Cuckoo's Nest. 

(Elissa)  That's what I think of.

(Dr. Caine)    It is a very, very different procedure with an anesthesiologist standing at the head, and a psychiatrist.  It is very highly monitored.

(Dr. Salgo)    Let's pause here for another moment, and let's sum up a few other key things to remember before we move on.  The goal of treatment for depression is remission.  To make you better as possible.  To make the depression go away.  Not to just get a little bit better.  Treatments include medication, psychotherapy, and other management, including electroshock therapy, if that is in fact what is left to do.

(Dr. Caine)    Although I call it electroconvulsive.  No shocks involved.

(Dr. Salgo)    Let me tell you a little bit more about Ginny.  Ginny was a good patient.  Ginny took her medication.  She saw a therapist and went to a counselor.  In about 10 or 11 weeks, she was feeling normal.  So, her question now is can she come off the drugs.  Can she come off the drugs?

(Dr. Beck)    Well, research shows now that people ought to stay on drugs for a much longer period of time than we used to think. 

(Dr. Salgo)    What about insurance?  Is insurance going to cover all of the SSRI,
tricyclics, and 100,000 visits to a therapist?

(Dr. Papa)    That's part of the problem that I said before when you said are they mutual exclusive, and I said they can be, because the patient just can't afford both, both the drugs and the therapy.

(Dr. Salgo)    Do they come to you if they can't afford to go the pills and the docs and everything else?  Do they come see you?

(Sheila)    I am not the only one.  Yeah, I would be an alternative.  There are many people who can't even afford-can't find a counselor or don't have insurance that can-

(Elissa)    Insurance won't cover all of the therapy that you need?

(Sheila)    No.

(Dr. Caine)    It is even more complicated than that.  First, remember there are almost 50 million people who are uninsured.  Our biggest population though since Medicaid covers a lot of people, our biggest population are the working poor.

(Dr. Beck)    Let me also say that for people with insurance that psychotherapy doesn't have to take forever.  We often see patients for 8, 10, 12 sessions, and they learn enough to get over the depression.

(Dr. Salgo)    I don't want to end here without asking how you are feeling.  Right now with us right here today are you better than you were?

(Mary Jo)    I am great.

(Dr. Salgo)    You are feeling back to your normal self?

(Mary Jo)    On medication I am great.

(Dr. Salgo)    I want to close with a few of the summary points that we really need to get to to make sure that people take away what they need to hear from all of us.  First, you need to know that depression is a serious health condition, which is under-recognized.  It is not a normal state of being.  Depression is a neurochemical disease causing major personal disability.  In fact, it is the number two cause of disability in the world.  Now the goal of treatment for depression is remission.   To make the depression go away.  Not just to get a little bit better.  Treatment is going to include medication, psychotherapy, medication and psychotherapy, and other kinds of management as well.  It is a very complicated subject, but there is hope out there.  You've got to know what you are looking at.  Again, thank you all for being here.  Our final message is this taking charge of your health means being informed and having honest communication with your doctor.  I am Dr. Peter Salgo, and I will see you next time for another Second Opinion.

(Narrator)    Search for health information and learn more about doctor/patient communication on the Second Opinion website.  The address

(Narrator)    Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent Blue Plans.  Committed to better knowledge leading to better more affordable healthcare for consumers.