In this video, Michael Thase, MD, discusses the management of treatment-resistant depression during the COVID-19 pandemic.
Dr. Thase is Professor of Psychiatry, Perelman School of Medicine, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
Read the transcript:
Hi, I'm Michael Thase. I'm a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania and also a member of the research faculty of the Corporal Michael J. Crescenz Veterans Affairs Medical Center, also here in Philadelphia.
No, that's not the Ben Franklin Bridge behind me. It's the Zoom background that seemed to cause the least interference with this recording. It's, of course, the Golden Gate Bridge. I'm talking to you this morning from Philadelphia.
I was asked to talk about how the COVID‑19 precautions have altered my professional life, particularly when it comes to treating patients with more difficult to treat or refractory episodes of depression.
I think most importantly, some of our more advanced strategies for patients with treatment resistant depression, or TRD, require the kind of on‑site presence that has been difficult to implement during the COVID‑19 restrictions.
The first order of business here at Penn was to have serious depression declared as one of the life‑threatening clinical conditions that we were allowed to continue to do in‑person interventions for. I'm pleased to say that that was relatively quickly approved without too much ado about it.
We were allowed to continue ongoing esketamine treatments of our patients who were already improving or stabilized on doses. We were allowed to continue treatment with TMS and to initiate treatment and continue with electroconvulsive therapy. This particularly has been available as an option for inpatients with the most severe and difficult forms of depression.
For everybody else, the care went virtual. My university negotiated a preferred provider in terms of HIPAA compliance with some assurance of better protection of confidentiality. So, we have been doing video conferencing. The quality of the picture I see in a video conference on most days is comparable to, hopefully, what you're seeing and experiencing right now.
In my experience, aside from the actual sense of being there with the person, you're able to observe psychomotor phenomena, the reactivity of the facial muscles, the ability to have a sense of humor, to smile spontaneously, and other indicators of the patient's overall level of global severity.
Of course, you go through...The visits seem to me to be a little shorter on video conferencing than they are live. You run through the very same kind of practice habits and paradigms that you normally do. The visits are 15 to 30 minutes long.
You can initiate just about every other therapy through this video conferencing. Even in the states of New Jersey and Pennsylvania, we were given emergency ability to initiate treatment with psychostimulants as a result of a video conference visit. Previously, those had required in‑person visits.
Likewise, we are not doing a study of any opiate right now as an advanced treatment. We are also not part of the psilocybin program. Those kinds of treatments, opiates, Schedule I controlled substances like psilocybin would require very closely monitored protocols, and at least in the case of psilocybin, also would require seeing the patient in-person.
As far as some of the more advanced Level 4 kinds of strategies that you think of for people who aren't responding to reuptake inhibitors and newer generation antipsychotics, tricyclics, monoamine oxidase inhibitors, lithium, thyroid hormone can be managed through video conferencing much the same way.
I don't have access to taking a blood pressure, so I will ask the patients to visit their primary care doctor or to even go to one of the drug stores that has the self‑monitored blood pressure cuff that they're able to use.
There are labs that are still available and still open. I send, instead of handing a prescription over, I make a PDF and send it to the patient that way when we need a blood level or some other lab.
Instead of using my own scale, I'll ask patients to weigh themselves so we can continue to keep a weight chart when there are issues with weight gain, especially during treatment with a newer generation antipsychotic or one of the older antidepressants.
Finally, I think it's a little harder to do psychotherapy through a virtual or video conferencing, but it's not impossible. The more you do it, the more comfortable you are at it. Again, there is just the tiniest bit of subtlety of being with the person, but there are some very good web-facilitated models for psychotherapy that actually can be more efficient in the delivery.
As you know, I'm an advocate for patients with difficult to treat depression having a full battery or full regimen of treatment that includes behavioral activation, exercise, and the kinds of interventions that you do in interpersonal psychotherapy and cognitive behavior therapy as ways of further enhancing their chances for recovery.
That's it from Philadelphia here this morning. I hope these comments were helpful. I guess the final thing I would say about how COVID‑19 has affected my life is it does amplify the sense of social isolation for the provider. I think it redoubles our efforts to stay in touch with each other and keep your collegial relationships going and so forth.
If you find yourself having discouraging thoughts, thoughts like, "Oh, this patient just doesn't want to get better," and so forth, it's a good time to reach out and have a pleasant social interaction with a colleague as a way of keeping your own objectivity and keeping your own spirits up.
Thanks again for tuning in for this this morning. I look forward to talking with you on another occasion.