Sunday, April 13, 2008

My Three Shrinks Podcast 45: Guest Ray DePaulo on Treatment Resistant Depression

[44] . . . [45] . . . [46] . . . [All]

We are pleased AGAIN to have the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo, joining us here to talk this week about treatment resistant depression (TRD), bipolar disorder, favorite quotes, and words we don't like.

Dr. DePaulo joined us on the last podcast (#44) and talked about cosmetic psychopharmacology, among other things.

April 13, 2008: #45 Guest Dr. Ray DePaulo on Treatment-Resistant Depression

Topics include:
  • Treatment-Resistant Depression. How is it defined (~10:00 min into the podcast)? Is there a magic bullet? Treatment strategies (don't give up; remember lithium; use proven agents; get 2nd and 3rd opinions; do psychotherapy).

  • Nellie, the Hypothetical Patient. Let her know what we know about treatment, and what we don't.

  • "Alternative" Treatments. St. John's wort; SAMe (s-adenosylmethionine); omega-3 fatty acids; ketamine; vagal nerve stimulation (VNS); deep brain stimulation (DBS); psychosurgery (cingulotomy).

  • Cognitive Therapy. Many different types.

  • Words which are Unliked by the Podcasters. Alternative treatment. Mood stabilizer. Antidepressant. Antipsychotic. Hallucinogen. Psychosis. Neurosis. Organic. Schizophrenia. Nervous breakdown. Mood Swings.

  • Quotations We Like.
    "There's only two types of music: good music and bad music." Fran Liebowitz
    "Eighty percent of success is showing up." Woody Allen
    "Expect more of yourself and less of others; you'll be disappointed less." Unknown
    "Life is unfair; the sooner you figure that out, the happier you will be." Unknown (Lilya said it in 2003 on a recovery forum)
    "A good clinician is someone who makes prudent decisions based on insufficient information." Ray DePaulo (I think)
    "Experience is what we call it when we were looking for something else." Federico Fellini
    "Good decisions are based on experience. Experience is based on bad decisions." probably Mark Twain
    "'Experience' is simply the name we give our mistakes." Oscar Wilde
    "Science is a process of conjecturing and refuting what is thought to be universal, therefore a theory can only be considered 'scientific' if it is falsifiable," paraphrasing Karl Popper.
    "It's a short step from the penthouse to the outhouse." Unknown (many found)
    "It's a short step from Who's Who to Who's He." Unknown
    "There ain't no such thing as a free lunch," or TANSTAAFL, by Robert A. Heinlein.
    "When Momma ain't happy, no one's happy." Apparently, an old southern saying.
    "For every aphorism, there is an opposite aphorism that's equally true." Unknown
    "Children can be happy when their parents are miserable. But a parent is never happier than her unhappiest child." Laura Lippman
    "Data is not knowledge, and knowledge is certainly not wisdom." Unknown

  • Drugs in the Drinking Water. Brief mention of last month's AP story finding all sorts of pharmaceuticals in numerous municipal water supplies.

  • Books we are reading.
    -Ray: "Saint Augustine", by Garry Wills.
    -Roy: "Valis", by Philip K. Dick. (Ben was reading it on "Lost".)
    -Clink: More listening to an opera about Carmen, a famous female sociopath.
    -Dinah: "How Doctors Think", by Jerome Groopman.

Dr. DePaulo's most recent book is Understanding Depression.

There are three audiences for this authoritative book: people who think they may be depressed, those whose condition has already been diagnosed and are in treatment, and those who are concerned about someone who is either in treatment or probably needs to be.

Find show notes with links at: The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.


Midwife with a Knife said...

Interesting podcast. :)

1) I didn't have any idea that Philip K. Dick had schizophrenia.

2) I would love to hear y'all talk about the military thing sometime.

um..... there was something else but I forgot.

NeoNurseChic said...

Looking forward to listening to this one!

I am curious to hear whether or not you explain why you don't like the words you do not like. I have words that I can't stand, and I have mentioned this before. My psychiatrist doesn't even use the word "fantasy" with me because he knows I absolutely hate that word. When he does use the word, he usually says something like, "If you'll let me use this word" or "I know you don't like this word" or something like that... I can't remember now the other word I'm always saying I don't like!

Quotes - One I must disagree with - the one about children being able to be happy when their parents are not. So untrue, at least for me. I was never ever happy growing up when my parents weren't - and I'm still that way. I remember having a long talk with my dad one Christmas about how I felt my mom wasn't happy, so I couldn't enjoy the holiday. My dad was explaining that Christmas is a stressful time for parents, and I said that it made me feel completely miserable knowing they were unhappy. Seriously - I have NEVER been able to be happy when they aren't - and I can always tell.

Couple of my favorite quotes:

"I am not afraid of storms, for I am learning how to sail my ship."~Louisa May Alcott
"Never fear shadows. They simply mean there's a light shining somewhere nearby."~Ruth E. Renkel
"There was never a night or problem that could defeat sunrise or hope."~Bern Williams
"Some luck lies in not getting what you thbought you wanted but getting what you have, which once you have got it you may be smart enough to see is what you would have wanted, had you known."~Garrison Keillor
"Thinking is the hardest work there is, which is probably the reason so few engage in it."~Henry Ford
"The nice part about being a pessimist is that you are constantly being either proven right or pleasantly surprised."~George F. Will
"A positive attitude may not solve all your problems, but it will annoy enough people to make it worth the effort."~Herm Albright
"Sometimes even music cannot substitute for tears."~Paul Simon
"The life so short, the craft so long to learn."~Hippocrates
"Keep breathing. The sun will rise tomorrow. And you never know what the tide may bring."~"Castaway"
"It happens." "What, $hit?" "Sometimes."~"Forrest Gump"

On the pills in the water thing - when I was in Florida, I was having my grandma clean out some of her old meds, and she mentioned flushing them. I said, "Nana! No way you can't do that! They end up in the water supply!" So then she was going to throw them out, but I told her not to throw out meds like ativan and xanax, since people might take them for abuse - so I suggested she bring them to the pharmacy or her doctor for disposal. Not sure what other ways to suggest! I never throw out meds because they are expensive and I often end up back on the same meds again at points in the future.

Anyway - I'll listen to the podcast soon! I finally have a few days off now.

Take care,
Carrie :)

Roy said...

MW, Which military thing?

Carrie, we do talk about why we don't like the words. I like the pessimist quote. Pills... when I closed my practice, I had all these expired samples that I had accumulated and didn't know what to do with. I put them in a trash bag and took them to the hospital pharmacy, where they put them in biohazard bags for incineration. That seems to be the best thing to do. Some pharmacies have started take-back programs, though they are not legally permitted to take back narcotics.

Anonymous said...

I hope someone sees the irony in discussing words you do not like and then making reference to someone's blog post about a Russian Nazi running a daycare in a concentration camp. Having done the parent of toddlers through teens bit, still doing it, it doesn't end, I have seen all types of daycare/teachers and while there where many I would have like to have strangled and some who were fired with cause for being abusive, and others who were just plain mean, over controlling and meddling, the words Nazi and concentration camp used in a jocular sense are particularly offensive. A true Nazi would have shot the kid, and concentration camps did not have picky eaters. Don't say chill, and don't say Seinfeld and soup Nazi. Think about it and where you were born and how a few decades and oceans made a big difference.


DrivingMissMolly said...

I don't know what I'd do without the "disliked" terms. I need them because they give me some feeling of control over my seemingly out-of-control illness.

Diagnoses and terms of art legitimize my "illness," my laziness, worthlessness, social awkwardness, anxiety and general misery and malaise.

They also legitimize psychiatry, right? If you don't sound "medical" you're going to look like less of a doc, a problem psychiatrists sometimes already have.

You know what I'd really like to know? Why are you guys so coy about revealing a diagnosis? I mean, what's the secret?

I have really enjoyed Dr. DePaulo and would like to thank him for freshening up the podcasts with his perspective. I think I have seen some of his videos on the Johns Hopkins' web site. How about a plug for those, as well as the book?

Roy: I really thought about it when you said that you thought that after seeing a patient a year and they didn't get better, that they should move on. I have seen my "new" psychiatrist for almost 2 years and don't feel better. I quit therapy also because I felt that it wasn't halping much after 5years and I didn't want to waste my therapists time anymore (free). I felt that if I wasn't going to change, then I didn't deserve therapy. Would you say that someone with comorbid (I don't know how to use that word) disorders should wait longer than the one year rule? And, Dr. DePaulo, my doc is an academic doc also (residence director, professor, education chair). Do academic docs only take certain patients?

I know I can't expect answers, necessarily 'cause all of you are so busy, but I thought I'd put some thoughts out there.


DrivingMissMolly said...


I know whose blog you are referring to. If you knew her at all you would realize that she (the original blogger) is a very warm and caring person. She was venting. People are allowed to do that on their blogs and, in my opinion, should not be judged by one post.

I read a blog that previously was called "The Drug Nazi" but is now called "Drugmonkey." Why the change? He actually met a concentration camp survivor in his store and the experience was life-changing.


Roy said...

Lily, I have no 1-yr rule or anything like that. In an old podcast (which one?) I recalled meeting a psychiatrist who did have such a practice of re-evaluating whether he wanted to continue with a pt after one year, taking into consideration whether he felt he was helping the pt and whether the pt was "clinically interesting". I found that to be a selfish way of looking at it, but expressed my own thoughts of how that would keep one's practice "fresh" and avoid accumulating many chronically ill pts (the ones who improve move on, the ones who do not stay).

I did not propose this to be a desirable state of affairs, though Dinah presents it otherwise.

But the bottom line for a pt might be to take the time periodically to assess what you are getting out of treatment, what are your goals, are you closer to achieving them, etc. Then discuss this assessment with your treating clinician.

Oh, regarding Philip K. Dick and schizophrenia... This book Valis is said to be the closest thing to his autobiography, where he talks about many of his psychotic thoughts in a more personal manner, very thinly disguising his first person account as a third person narrative from a guy called Horselover Fat...

"Horselover Fat's nervous breakdown began the day he got the phonecall from Gloria asking if he had any Nembutals. He asked her why she wanted them and she said that she intended to kill herself. She was calling everyone she knew. By now she had fifty of them, but she needed thirty or forty more, to be on the safe side.
At once Horselover Fat leaped to the conclusion that this was her way of asking for help. It had been Fat's delusion for years that he could help people. His psychiatrist once told him that to get well he would have to do two things: get off dope (which he hadn't done) and to stop trying to help people (he still tried to help people)...
I am Horselover Fat, and I am writing this in the third person to gain much-needed objectivity...
The night before, Bob and I-I mean, Bob and Horselover Fat-drove to Oakland to see the movie Patton. Just before the graveside service Fat met Gloria's parents for the first time. Like their deceased daughter, they treated him with utmost civility. A number of Gloria's friends stood around the corny California ranch-style living room recalling the person who linked them together. Naturally, Mrs. Knudson wore too much makeup; women always put on too much makeup when someone dies.

According to Wikipedia, "Horselover Fat" is a semi-translation of Phillip Dick: "The main character in VALIS is Horselover Fat, an author surrogate. "Horselover" is English for the Greek word philippos (Φίλιππος), meaning "lover of horses" (from philo "brotherly or comradely love" and hippos "horse"); "Fat" is English for the German word "dick"."

DrivingMissMolly said...


Thanks a lot for your responses. I haven't asked my doc lately but he has told me several times that he would not continue to see me if he did not think he could help me.

I am tired of jumping from shrink to shrink. Part of my illness? Do I need to move on? Who knows. I don't trust my own judgment, but I'm the one in charge....on well...

Thanks! I am looking forward to the next podcast.


Anonymous said...

Coming in very late, but ...

Glad to hear "anti-psychotic" is on the hate list.

Never thought about it before,
but much unproductive worrying could have been eliminated had I been given a drug to "turn down the dopamine & calm thoughts-gone-wild-and-wonky" rather than an "anti-psychotic."

This was before anti-psychotics turned atypical though; their use is so broad now that hopefully this gets explained more. Still, psychotic is still a powerful and scary word to someone hoping to avoid the hospital this time.