NP Notes: Patient Burden of Major Depressive Disorder (MDD Episode 2)

Craig Chepke, MD, DFAPA: Hello and welcome to the Great Exchanges in Mood Disorders podcast. I'm your host, Craig Chepke. I'm a psychiatrist at Excel Psychiatric Associates in Huntersville, North Carolina, and the Scientific Director of Psych Congress. I want to welcome my colleague, Margaret Emerson to the podcast today. Margaret, tell us a little about yourself.

Margaret Emerson, DNP, APRN, PMHNP-BC: Hi, thanks so much for inviting me. So, I am a clinical associate professor at the University of Nebraska Medical Center and work with integrated care and do some digital technology in the primary care space. So, thank you for having me.

Craig Chepke, MD, DFAPA: So excited to have you here today. So, we're going to have a great discussion about MDD today. We've got a lot we could talk about. But, I'll try and keep us narrowed a little bit. So, you're integrative care, but let's take an integrative approach. And what are kind of biological and socioeconomic factors that are associated with MDD?

Margaret Emerson, DNP, APRN, PMHNP-BC: So, MDD covers a large amount of different factors. So, we're thinking multifactorial, so it'd be involved biological factors. We're talking socioeconomic factors that contribute to MDD. So, if people are under lots of stress or if they experience trauma, also life circumstances of things that are going on with them can all contribute to potential major depressive disorder. We also know there's genetic contributions that occur as well. So, if family members have a history of depression, they could be at risk for depression as well.

Craig Chepke, MD, DFAPA: Yeah, I mean, MDD is fairly heritable. And we also, though, as we need to think about the heritability of medication response, it's really probably the only biomarker we have in psychiatry is what worked well for a family member who had similar symptoms. But I love how you talked about what we might call the social determinants of health or social determinants of mental health. You know, so important to consider that when we're thinking about our patients and how they get to where they're at and how we can get them to be better. It's really easy to tell someone go and exercise, but what if they can't afford a gym membership? What if they live in a neighborhood where they don't feel safe going for a run? To eat healthier? Well, what if they can't afford healthy food? What if they live in a food desert where they just can't purchase any healthy food? There's no grocery stores that sell it, things of that nature. We really need to consider that, don't you think?

Margaret Emerson, DNP, APRN, PMHNP-BC: Yeah, a hundred percent agree with you. I think that's when we come down to that clinical sense of just the practicality of really individualizing what we're thinking about doing with patients needs to come down to those fundamental aspects of, can they even get to the clinic? Are there things that we can do to help support them? What does their family life look like at home? How can we support them there? Because that all plays into if they can even fill a prescription, if they're going to be able to take a prescription, if they understand why they're doing that. So, I appreciate you highlighting those things because they are incredibly important.

Craig Chepke, MD, DFAPA: Yeah, absolutely. Do you work with a lot of social workers in the practice?

Margaret Emerson, DNP, APRN, PMHNP-BC: So, I feel like I take on a few different roles, and I find myself doing some of those roles just because I think they are so important. But I also have a behavioral health provider who serves as a therapist. Then also helps me coordinate things. Because I'm in the primary care environment, we have a lot of tools and nursing support staff there to help us facilitate some of the needs because it goes beyond just treating depression. I mean, when we're in integrated care, we're really thinking about the whole person. So, what is going on with them medically? What is going on with them psychiatrically? And so, those resources really need to be allocated to all of those things that we're recognizing. And really prioritizing what is going to make the most difference for us to get to that end goal of having improvement in their mood and what resources do we need to pair that patient up with. And it's a very rewarding experience to see some of those goals actually be achieved. It can take a little bit, but it's fun to work as a team and get them to where we need to get them.

Craig Chepke, MD, DFAPA: Yeah. And I totally agree, and I always say that social workers are so important to mental health outcomes. When I met the best social worker in the world, I literally married her to make sure she'd always be by my side, fighting for our patients together because we’re on the same wavelength on a lot of those things. And so, we really do have to pay attention to all of those. I was really intrigued by one thing that you mentioned about you kind of draw on the interplay between the mental health and the physical health. And talk to us a little bit more about that for our audience.

Margaret Emerson, DNP, APRN, PMHNP-BC: So, one of the reasons why I decided to go into integrated care is because when I was doing traditional psychiatric practice, it seemed like there was a disconnect between managing some of the medical comorbidities and the interplay of what I was doing psychiatrically for them in terms of medication management. So, I would find myself calling primary care providers and say, “Look, I'd love for them to get a wellness check, and I'd love for you to get annual labs because that will really inform what I'm doing.” And that's a cost-effective way for us to get them engaged in care long before we're starting to see a lot of these challenges that they have. And so, it was just a natural, I think, transition for me to embed myself in primary care because we are working with medications that affect their cardiovascular function, their metabolic functions. And so, being there, it's sort of like an all-in-one situation where I have the people and the team together so we can address those things. And the patient really starts to see that it's not just about one aspect, it's about the collective whole of how do we help improve their health, not just for today, but for the long-term outcome.

Craig Chepke, MD, DFAPA: Right, because I can just imagine someone with major depressive disorder very commonly has anhedonia. They don't want to do really anything including maybe taking care of their diabetes, their hypertension, their asthma, or COPD, whatever it may be. And so, their physical health can really suffer from having untreated or undertreated mental health conditions like major depressive disorder, right?

Margaret Emerson, DNP, APRN, PMHNP-BC: Exactly. You know, there is kind of this bi-directional relationship between the medical comorbidities, cardiovascular things, metabolic stuff, and it works back and forth. So, if the depression is not going well, those other health problems are going to be affected. And vice versa. If someone is really struggling with their medical conditions, that could be a precipitant for depression. So, for us to have the opportunity to really focus on that is kind of a unique experience, but it does involve making sure that everybody understands the relevance of not just treating mental health or treating medical stuff, that everybody has to collectively work to treat both of those things. So, that takes a little bit of education, but, again, it's fun work.

Craig Chepke, MD, DFAPA: Yeah, and you mentioned that disconnect between the psychiatric and the rest of the body, and I never really understood that either. Where I did my psychiatry training, all my attendings were dual trained in internal medicine and psychiatry. And they taught me from day one, you're a physician first and a psychiatrist second. And that really stuck with me. So, when throughout my training and career would hear some psych providers say that, “Oh, I only treat above the neck.” It never made sense to me. You know, would you go to a cardiologist that’d say, “Oh, I don't look at anything below the mid sternum.” Like, well, what about the connection between the kidneys and the heart? That's kind of important, right? So, we do really have to consider these. And you mentioned the effect of our medications on the person's physical health and wellness, but there's a lot of nonpsychiatric comorbidities in MDD, even if you disregard the medications. Tell us about that.

Margaret Emerson, DNP, APRN, PMHNP-BC: So, we see a lot of, I mean, sleep is a big component that we see with either they have COPD or they have obstructive sleep apnea. So, that all can directly affect depression. We also know depression has results with us having impairments in sleep. And so, that can lead to fatigue or motivation. So, just some of those basic things of inquiring, you know, what is going on with that patient at a very practical level can help inform, do I need to have them work more intensely with their primary care provider? Is this something I need to look into in terms of evaluating labs potentially of things that might contribute such as thyroid disorder? So, there's just a lot of interplay. And so, being able to collect all that information and customize it for the patient is so important because we can easily go down a road of prescribing something that is not going to work because we haven't really nailed what was going on in the first place.

Margaret Emerson, DNP, APRN, PMHNP-BC: So, I always come down to the most important thing is an accurate diagnosis. And that diagnosis really has to come from an accurate assessment and really understanding what are the contributing factors. Because that will just drive all the decision making of what medication I'm going to use, what type of psychotherapy, what sort of resources I would need from primary care and my social worker. And I wish I had a marriage relationship with a social worker like yourself because that would be pretty handy. It's one of those things that it drives all of that decision making.

Craig Chepke, MD, DFAPA: Also handy in my personal life as well. So, I have obstructive sleep apnea and been on a CPAP for 12, 13 years. And there've been three times I went out of town and forgot my CPAP, and my amazing wife found local DME companies that would rent me one for 48 hours so I could get back home. So, I wouldn't even have to go a single night without having that. And if I was left to my own devices, probably would not have happened.  

Margaret Emerson, DNP, APRN, PMHNP-BC: Yeah. That's nice.

Craig Chepke, MD, DFAPA: So, social workers are amazing. So, let's talk about, though, the quality of life and the impairment that MDD can have on people in their lives. What do you see there?

Margaret Emerson, DNP, APRN, PMHNP-BC: So, because I work in that integrated environment, we see kind of the gamut of what can occur. So, we have folks that aren't able to even go back to work because they're really struggling with just even getting out of bed. So, the thought of them going to work is kind of a daunting task. We see folks that end up isolating themselves. They're not able to engage in things that they'd like to because they just aren't motivated. They're struggling to get out of bed. They have no interest in hanging out with folks. And so, we see people kind of backing off from the things that they would usually enjoy when they're having major depression. And then, also they're not caring for themselves for—maybe they're not eating well, maybe they're not exercising the way we'd like to. And that, again, going back to kind of the start of this conversation, affects all of their aspects of life.

Craig Chepke, MD, DFAPA: Yeah. So, to that point, when I walked into the office this morning—well, I mentioned already that I work with my wife. My mom is my secretary, actually. So, the first thing that my mom told me when I walked into the office this morning is that I needed to write a medical leave note for one of my patients to start FMLA paperwork. And this is an individual with MDD. So, this is something that is incredibly prominent and really causes a lot of disability and dysfunction. And the World Health Organization has declared MDD, depending on what year, either one of or the most common source of disability worldwide. And certainly working in primary care, embedded in the primary care setting, that's, you see that from the very genesis.

Margaret Emerson, DNP, APRN, PMHNP-BC: Yeah. Well, you bring up an interesting point about just kind of the medical leave. Oftentimes, if we're dealing with adults, these could be parents. So, this is going to affect not only their work relationship, but also their ability to take their kids to their activities or to be engaged in the way that they would like to. And then, that results in a lot of potential guilt and feelings of not being adequate. So, it's just a large issue that affects so many different paths in our lives. So, it's so important that we're very astute in assessing these things and providing those resources to folks.

Craig Chepke, MD, DFAPA: Yeah. And that's where we have to be aware of certain other differences and disparities. That, in general, MDD affects women disproportionately compared to men usually. The statistic we hear was two thirds versus one third, two thirds female, a third male, on average. But also, women generally stereotypically handle more of the household chores, the finances, the childcare, et cetera. And so, that there can be a cascade. Now, that can happen with men too, but women disproportionately shoulder a greater burden in most family settings. And so, we need to be cognizant of that when we're thinking about the dysfunction that MDD can cause.

Margaret Emerson, DNP, APRN, PMHNP-BC: And I think we're seeing the idea that reproductive factors are a significant contributor to women experiencing depression or other mood-related disorders. And I'm so glad that this is coming to sort of the forefront of what our focus is not just in the United States, but globally, because it doesn't just impact the mom. It impacts who she's caring for, who she works for, who she has family with. And so, I'm glad to see that there are initiatives supporting that work. That is one of the areas that we're building out a little bit in terms of a digital clinic and really supporting those moms. Because I look at it like it's a two for one, at least. At minimum, if we take care of that mom, then she can take care of her kiddos, and the benefits are exponential, I think, after that point.

Craig Chepke, MD, DFAPA: Absolutely. Well, I want to thank you for joining us today, Margaret, and thank our audience for joining us on the Great Exchanges in Mood Disorders.

Margaret Emerson, DNP, APRN, PMHNP-BC: Thank you so much for having me. It was a pleasure.