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Hello, everyone. Thank you all for, for, for joining. I'm excited to be here and we're gonna jump right in. Uh the title of today's conversation is called What's Left Behind. Uh Hopefully that has an ominous feel to it as we wanna talk about the residual symptoms and effects uh for our patients who are experiencing major depressive disorder. Um One thing we know is that we use medications uh quite often uh in the treatment of major depressive disorder, but we also know that medications don't fix everything. So we're gonna talk about some of the other strategies and some of the things that medications don't address, uh and how to remedy those things. So, jumping right in, uh on this slide, you're gonna see some of the symptoms uh that are improved by the use of medications for the treatment of major depressive disorder and many of these things, as you know, some of them are emotional, some of them are more kind of physically related symptoms. So for instance, sadness, crying spells, uh low energy changes in appetite, um disrupted sleep, even suicidal thoughts or one's ability to experience pleasure with the appropriate antidepressant medication treatment our patients, you know, oftentimes will experience improvement in these things, uh, and these are not insignificant. And so that's, uh, there's absolutely a role for medication treatment. Um, but let's also talk about some of the things that medications don't quite address as effectively. So some of the things that can linger will include, uh, cognitive symptoms, perhaps even some of the emotional blunting, um, and other more kind of habit related things. So we have, we're gonna walk through some of those. So, on the cognitive side, oftentimes, uh patients will describe brain fog uh as one term or some difficulty with processing or concentrating for extended periods of time. Uh Many of our patients are uh working or at school or have responsibilities in their home environment and they just don't feel as sharp or as able to kind of keep up with those demands and they'll use words like, you know, I feel slower, I feel sluggish. I feel like I'm in a fog. Uh and that can lead to things like indecisiveness or making errors and just feeling cognitively, not as sharp and that's significant when it comes to function and quality of life considerations. Next is on the emotional side, just feeling flatter or just blunted where, where they will say, you know, yeah, it's true. I'm not crying as much and, you know, I don't feel as sad, but at the same time, I just, I don't really feel happy yet either. I you know, something great happened with one of my kids and I just, you know, wanted to celebrate, I wanted to be excited for them and I just couldn't quite get there. I couldn't quite access that level of positive emotion. So that lid or that ceiling that tends to happen. Um in certain cases where they feel their emotions are just a little bit blunted or a little bit duller also, uh issues around, uh not being able to finish tasks or not feeling as confident in themselves again, maybe not as depressed emotionally, but that level of confidence or self esteem isn't quite there yet. Uh And then, uh, you know, in a significant way, um, our patients are oftentimes engaging in certain behaviors or certain habits when they're depressed that even once the depressive symptoms are improved, those habits, uh don't go away overnight. And so they may still be stuck with certain addictive patterns around food or substances. They may have made some unhealthy financial decisions when they're depressed or neglected certain things they've fallen behind on their bill payments or on checking their mail. And so now there's a lot of catch up to do and phone calls that they have to make to try to do, dig themselves out of the hole. And unfortunately, there's not a, you know, medication pill to kind of do that for them. It's gonna re, you know, requires, uh, more effort and hands-on things, uh, or more support And so that's some of what we're gonna cover uh in terms of the strategies to address those things. Similarly. Um We know that our patients with depression are involved in relationships and live with other people and go to work and have to interact with, with, with people. And so there are other consequences, particularly interpersonal consequences um from how they have communicated or behaved or not communicated or not behaved uh when they were in a depressed state. And so oftentimes, even when certain family members accompany them to their appointments or their loved ones, send you an email saying, hey, doc, I really want you to know what's really going on back at home or, you know, they're, they're doing better emotionally. But here's the, you know, here's the damage that was done when they weren't doing well. And oftentimes their family members or loved ones are communicating some level of caregiver for caregiver, fatigue or burnout or a frustration or resentment. Um or, you know, the patients have isolated themselves from friends and family during their depression. And so now when they're ready to reenter and reconnect, sometimes those friends and family are quite ready and they, they have some feelings, they've got some frustrations or um you know, some things that they need to kind of resolve before they're ready to reconnect. Also, when it comes to responsibilities at work or at school, there are oftentimes can be consequences related to what happened. Uh when they were depressed. So falling behind on assignments, uh feeling disconnected from classmates or colleagues, uh missed opportunities for promotion or certain projects that they were looking forward to that they missed because they, they were not available emotionally, mentally, physically, et cetera when they were struggling. So these things really are impactful, uh and important for us to consider as we're treating our patients realizing that yes, medications are very helpful in many cases, but they only go so far. And so we wanna be mindful about the other things beyond medications that we can do, uh, for our patients in these cases. So, speaking of cases, we're gonna dive into, uh, a case of a patient I treated a few years ago. Uh, we're gonna call her Mary, uh, for the sake of conversation. That is not her real name. Uh, Mary was a 27 year old female. Um, she was very smart. She, um, uh, worked at Google, uh, uh, had a computer science degree was very gifted in that regard, uh, but had fallen on, on hard times due to depression and her other mental health disorders. Uh, and in this case, she and her fiance had recently ended their engagement. She had a somewhat strained relationship with her parents, uh, parents divorced. And so it was dad and step mom that were her primary support, but because of her behaviors and attitudes, she had kind of burned some bridges, uh, with family and with friends by the time of her coming to me and my team for depression treatment. Um, she had been through a couple of rounds of E CT, which is electro electroconvulsive therapy. She had done a lot of trial and error with medications. She had been to a couple of other treatment programs. One that was more trauma focused and just was feeling really defeated, uh, and having a level of desperation and frustration with the treatment process, realizing that there wasn't a medication or combination of medications that was gonna be the magic fix for all that she was experiencing. And Mary had multiple diagnoses. So one of them was major depressive disorder, but she also suffered from borderline personality disorder, posttraumatic stress disorder and obsessive compulsive disorder. So, as you can imagine, there's a lot happening for her psychologically. Um that is leading to her level of dysfunction and disability. Um Part of what we discovered, which I'll touch on a little bit later is she also had traits of autism spectrum disorder. Um in some ways, she was gifted in that regard with her neuro divergence and was able to really hyperfocus on certain things and had a high level of intellect and knowledge for uh for her job skill. But at the same time, on the social and interpersonal side, she struggled with uh with rigidity in her thinking patterns and rules and wanting things to be a certain way. And when they weren't a certain way she really, you know, had, had meltdowns and with struggle and that would come out as emotional dysregulation and lashing out verbally and really wounding some of the uh support relationships that, that she had in her life. So with us, um uh she entered treatment, we did some medication changes including anti antidepressants as well as mood stabilizers to target some of the agitation. Um We had her undergo extensive psychological testing to give her and us a little bit more clarity on her diagnoses and really to empower her with an understanding of what was going on internally. A lot of times as you all may have experience with your patients, there can be a lot of shame and selfcriticism associated with it because mental illness, I it feels personal, it is personal and a lot of times where, you know, conversely, if someone has a broken leg, uh they don't necessarily feel like a bad person. But if someone has depression and a personality disorder and trauma and has, you know, heard a lot of negative things about themselves from their loved ones or a lot of, you know, kind of arguments that affects their self image and self esteem. And so we want to use diagnoses uh as a way uh that is informative and empowering and not a label. We don't just wanna pile on labels or more shame. And so we really try to be intentional in the language and the messaging. We use when we're doing testing and sharing diagnoses with our patients. Uh Mary, in this case also did transcranial leg stimulation. Uh We worked with uh her and her parents in family therapy. Um There were some times where we had to put her on a wellness plan also known as kind of a, a behavioral contract saying, hey, we're noticing that you're doing XY and Z that is actually interfering with your treatment when you lash out at your therapist, when you refuse to do your homework assignments, when you are, you know, complaining about other patients issues here, that's actually distraction from the work that you need to do and it's getting in the way of your recovery. So if you can adhere to these three things, here are some rewards, here are some incentives that we will give you to help reinforce your healthy participation in your treatment. So there's, you know, uh there's some uh what I would say, kind of even, you know, reward or kind of pediatric reward models that we can use and leverage for, for, for behavior change. Many of us as humans are motivated by rewards. And so let's use that in a healthy way, incentivize our patients doing the work in their recovery. Also, uh in uh in Mary's case, uh work was super important. Uh And so by the time that she came to us, she was on disability, long term disability from her work at Google, but had an interest in returning and knew that when she was well work was something that was good for her. So, treatment response. Um Thankfully, in this case, she had an improvement in her depressive symptoms. Were you able to track that using a clinical rating scale? Uh in this case, the, the moderate scale, the Montgomery Asperger depression rating scale seeing that she came in with very severe marks and uh had more mild to moderate marks by the uh end of her treatment with us. Thankfully, we were able to give her and her parents more effective communication strategies where they were not just lashing out at each other in frustration and blaming each other and finger pointing, but being able to practice things like validating the other side, making a request nonjudgmentally uh and using more affirming language rather than critical language. And that really went a long way in the relationship. One of the things as I mentioned on the front end was that um she had just ended an engagement with her fiance in the months preceding her time in treatment with us. And so she and her fiance or rather ex fiance at that time, still owned a home together. And so they were having to make some important decisions around selling the home or was the fiance gonna buy her out of her share of it? You know, they were both on the mortgage. It was really complicated and they were not really on civil terms by the time that she came to us, however, through some coaching and therapeutic work, she and her fiance were able to collaborate effectively on the sale of, of their home and do it amicably. Um She moved through our uh level system here, we have a residential program followed by a kind of a step down treatment program. She was able to move to our transitional housing environment and then uh was able to um provide uh or secure her own apartment and resume independent living, return to work and stayed engaged uh in our uh alumni program for patients who complete our program and want to stay connected to our community. So really want to highlight that um what we're describing is, you know, a number of very nuanced situations, interpersonal situations, communication with loved ones, work considerations, needing accommodations and a and a plan of how to return to work gradually and and ramp back up to those responsibilities rather than getting in a jumping in full time again. So really things that are beyond the scope of what just medication treatment targets uh but are equally important. And I would argue in many cases, even more important to our patients experiences and their quality of life when it comes to actually navigating these things in real time. And so along those lines, I hope this highlights, you know, some of the important issues related to what we have to help our patients with. Uh as it relates to the residual symptoms and residual effects of dealing with depression. Um Some of the things to consider um that you may be able to offer patients or to refer them to. Again, none of us have to be uh a one man show or kind of the nonstop shot. I don't do it all. I, you know, have a certain level of skill and ability when it comes to medications and therapy. But I really rely on my colleagues for other types of therapy or other types of resources when it comes to career coaching or school accommodations. And so realizing that, you know, they always say it takes a village to raise a child, it takes a village to also to treat mental illnesses. And so um being able to form strategic partnerships with other providers, uh other resources so that you have a team approach in the care for your patients. Uh and those things can include marriage or couples therapy, like I said, career coaching or school accommodations and then encouraging our patients to get involved in their local communities, whether it's social groups online or in person, huge opportunities online with Discord communities and Facebook groups and all kinds of support groups uh even within, you know, certain mental health organizations. So really, you know, pointing patients in that direction, encouraging them to get physical, to get active when it comes to exercise or team sports or joining a gym and more than just joining a gym, take a class to have that kind of group fitness and group accountability related to getting some exercise in. And then for certain patients, uh their faith and spirituality can be a big anchor for them. So directing them to groups or organizations that can help support them in that regard, so that they're not alone. It's really we know that with depression especially it, the illness itself can be very isolating and very disconnecting. So what can we do to help reengage and reconnect uh our patients with the things that are gonna help to keep them well? Ok. So hopefully some of these tips and strategies and looking over that uh case um was, was helpful and uh I'm grateful for your time and attention and hope you're able to use some of these things in your clinical practices. Thank you again.