Dr. Keith Horner

By Kevin Tankersley

Part 3 of our mental health series: A conversation about depression and anxiety

Dr. Keith Horner has been practicing family medicine in Waco since 1990. He graduated from Southern Illinois University Medical School in 1987 and completed his residency at the Family Practice Center in 1990. Horner is board certified in family medicine.

Horner and his wife, Bridgett, have two children: their son Christopher, who graduated from the Key School of Fort Worth and is now working; and Madison, who will graduate from Baylor University in May and, a week later, begin the physician assistant program at UT Southwestern in Dallas. The family will take a quick trip to Colorado between those events.

According to the Depression and Bipolar Support Alliance, nearly 15 million Americans 18 and older have some sort of major depressive disorder, and 1 in 8 adolescents suffers from clinical depression. Horner said that in the 28 years he’s been in practice, he’s seen more and more patients with anxiety and depression and has seen great increases in the number of young patients dealing with these as well.

For the third, and final, installment of our mental health series, Horner sat down with Wacoan writer Kevin Tankersley to talk about some causes and treatments of depression and anxiety, their respective phobias, and how he found his way to Texas from Illinois.

Horner began by talking about documents he has patients complete when they first come to see him and are showing any symptoms of depression or anxiety.

WACOAN: How do you go about determining if a patient has anxiety or depression?

Horner: This is the form we traditionally give people as a screener. Usually when people come in and there’s some questions, or just as a screen of the generalized population, we do [these forms] on the computer.

If the answer is zero on both, usually we’re done because these two are the top two indicators of depressive symptoms. If those are positive in some way, then usually the computer gives you the whole display. So this is a standard PHQ — Patient Health [Questionnaire] — measure of nine different questions, and these look for the criteria of depression.

Secondly, anxiety tends to occur a lot in people along with the depression. And this is a quick screener of the most common symptoms for anxiety. So fairly quickly, we can take what’s kind of a vague, nebulous subject and try to help them quantify and also look at the symptoms.

WACOAN: How did you end up in Waco from Southern Illinois University?

Horner: I met my lovely wife via my sister, who went to Baylor. Fell in love and knew I had to be here in Texas because when I asked for her hand in marriage — her dad’s from Lubbock, and he said, ‘I will grant that as long as you keep my daughter in Texas as long as I’m alive.’ So that’s how I got to be in Texas.

WACOAN: And have you done that, kept her in Texas all this time?

Horner: I have. He unfortunately passed away a year ago, but it’s the best decision I ever made, both in marrying her and in staying in Texas.

WACOAN: Since you started practicing here in Waco in 1990, have you always worked with depression and anxiety patients?

Horner: Yes.

WACOAN: Has there been an increase?

Horner: Yes.

WACOAN: Any idea what’s causing that increase?

Horner: I think the demands of life and how people that are susceptible to depression and anxiety, sometimes the way they compensate for it and how they adapt and adjust to it is different. People are drinking more beer. People are using more drugs.

Some people, I think they’re doing some of these things to compensate for how overwhelmed they feel. I think people do feel overwhelmed to a certain degree. And the fast pace of life, the demands of work, the [cost] of health care insurance. The kids, the stress that they feel with raising their children.

Doing this over the last three decades, I’ve seen all of those stressors increase. And I think anybody that’s genetically susceptible to depression or anxiety, if you put them in the pressure cooker long enough, a lot of times you’ll see a manifestation of these problems.

WACOAN: Are depression and anxiety genetic? Can they be passed down?

Horner: They may be. A lot of the recent studies that are looking at this, they’re looking at certain genetic markers that may predispose you to having increased activity in something called the limbic system, for anxiety.

So anxiety, the limbic system in the brain is in charge of fight-or-flight [responses]. So it has a useful purpose. If you’re in trouble, you want the limbic system to be able to fire. The problem is there are some people that the connectivity of the limbic system — it fires too much, and you can get generalized anxiety attacks. Some people get panic attacks; it’s a high firing within that area to the point of feeling overwhelmed or impending doom. What we find is that in those individuals, the anxiety tends to take over their life, and they become overwhelmed. It affects their social capabilities and the way they function too at their work and home.

WACOAN: Is there a difference between panic attacks and anxiety attacks?

Horner: There is. Anxiety can be what we call generalized anxiety, but panic attacks are a sudden moment in time in which there’s a high degree of electrical activity in the limbic system.

When you look at it on PET [positron emission tomography] scans, it looks like a seizure, but it’s not involving the cortex of the brain. It’s involving only the limbic system, so there’s no motor activity with the arms and legs like with classic seizure. But what we find is that medicines that help calm down seizures, like Xanax and Valium, have a tendency to short-circuit that panic attack.

The difference is it’s a sudden electrical activity within the limbic system that everything stops. It can be triggered by going over the Twin Bridges. It can be triggered by a variety of things that help prompt a panic attack. And sometimes you go, ‘I don’t know what the trigger was. Just all of the sudden, I thought I was going to die, I had chest pain, I was short of breath.’ Many people end up going to the emergency room the first time because they truly think they’re dying. So it’s this impending doom that occurs with them.

WACOAN: Do phobias cause those sometimes?

Horner: Not always. And phobias are actually within the genre of anxiety disorders. Phobias can occur even without panic attacks. I have a phobia of heights, and I don’t have a panic attack. There’s not this sudden impending doom, unless you push me out on the ledge. Then I might have a panic attack.

But for the most part, phobias are an unrealistic or overresponse to certain things that might scare you. Some people have it to snakes. Some people have it to spiders. Some people have it to heights, like myself. But those are more situational. Panic attacks, those are actually activity within the brain that creates an overwhelming response of symptoms that are consistent with anxiety.

WACOAN: Is your phobia of heights about tall buildings or outside heights?

Horner: For me, it’s mountains. It’s ledges and driving near Independence Pass as we go up to the higher heights in Colorado. I just feel like I have no control.

And I will tell you, it’s a common theme for most anxiety issues. You feel overwhelmed, and you feel like you have no control. A lot of times people spend most of their time trying to establish some level of control, whatever that is, that makes them feel better that they have the situation under control.

WACOAN: How do you deal with your fear of heights? You said you’re going to Colorado when your daughter graduates. How do you deal with that?

Horner: Sometimes I just basically say, ‘You know what, I don’t have to be a man to do this. My wife is a much better driver than I am.’ So I pulled over to the side one time, and she drove up.

WACOAN: Were you OK then?

Horner: Yeah, I was fine. Then the second time that we went a couple years ago, I said, ‘I’ve got to do this. I’ve got to do it for me. I’ve got to stare down the challenge, and I’ve got to rise above it.’

My hands were shaking at the time. It’s near Independence Pass as you go up to Aspen. And I cut into the other lane so I wasn’t so near to the outside. But I try to control my situation by controlling the variables that make me feel more comfortable. And I made it.

WACOAN: Here’s one reason I asked that. When I came into your building, I saw the big, wide staircase, and I was glad there were stairs that can be easily found because I’m claustrophobic.

Horner: Oh, you are?

WACOAN: Yes. I try not to do elevators or flying. It hit me the other day. I was getting my car washed, and I was driving through the car wash and all the suds were on the windshield and I couldn’t see. And it hit me right then. I thought, ‘I can’t get out of here right now. I can’t open my door and get out.’

Horner: You know, a lot of that, the fields of cognitive-behavioral therapy and desensitization are very helpful. Literally being exposed to those situations over and over and over again desensitizes you to it for many of them.

The other thing too, with flights, that can affect your ability to work and function in certain ways. I have no problem using small doses of benzodiazepine in some people, like a little baby dose of Xanax, an hour before they get on the flight. And it affects GABA receptors, which are the main calming effect on the human brain in the limbic system. So prior to those episodes, they’ll take it an hour before they get on the plane, and they’re calm as a cucumber. They’re able to do whatever they want. They can still function. Do not mix alcohol with it because it can be sedating.

WACOAN: I was just thinking that I would have a glass of wine with that.

Horner: The GABA is affected by alcohol too. The Xanax though is a little easier to control in the sense that it has a little more inhibitory effect where you just go, ‘I feel totally relaxed.’ It lasts longer than the alcohol would. You get about seven to eight hours on the Xanax, whereas the alcohol can peak and then drop.

WACOAN: Now back to an increase. Have you seen an increase in younger patients?

Horner: Yes.

WACOAN: Is that due to those other reasons?

Horner: It’s really multifactorial. Some of it is genetics. We see more anxiety actually in less-than-20-year-olds. I mean, if someone’s going to have anxiety, we tend to see the first glimpses of that when they’re teenagers and sometimes even younger.

I think kids are asked to do a lot more at a younger age now. In kindergarten, I was just coloring, sitting in my seat and learning not to talk. Now, if you’re not reading by the time you get into kindergarten, something’s up. So the demands that we put on you to be the good student start at earlier ages, and some of the kids, they’re not ready for that. And those that are predisposed to anxiety, well golly, that’s an anxiety-provoking component. With going to school and high demands and feeling overwhelmed, if there is a genetic tendency towards [anxiety], we tend to see it.

Now the other thing too, homes have totally changed. There’s changes in divorce rates. Kids are going to be with mom this weekend and dad next weekend. There are a multitude of factors there that play a huge role too. I also think the changes to the family structure, and society as a whole, the priorities that we have are totally different than perhaps we had when I was a kid.

Sometimes I think those of us in the older generation, which I include myself [in] — I saw life like ‘Mayberry R.F.D.’ It was ‘Leave It to Beaver.’ It was simple. It was just easy stuff. And so the stressors that were on me as a kid, maybe I romanticize it too much, but it seemed like a nice, easy life.

Some of these kids are exposed to drugs in one or both parents. Some of these kids are exposed to all sorts of horrific activities, whether it be physical, sexual or emotional abuse or emotional neglect. And so for a child to be born in a home environment in which this is a persistent stress for them, stressors can unearth those tendencies and can really formulate you to who you are and how you deal with the world.

For some of these kids, they’re on their guard all the time, and it really predisposes them to try to control things. I believe that’s part of the reason, too, why a lot of these kids are experimenting with drugs, trying different things. They smoke pot because they can sleep better and they feel less anxious. So I think a lot of these things start out innocent enough, but I think the root issues are very deep and very multifactorial.

WACOAN: You said they’re exposed to all these things. Does social media come into play there?

Horner: I think it does play a huge role. Those are things that you and I never had to deal with as kids. If you’re not connected on social media, you’re an outsider. Like when I look at my daughter, she and her friends, they’re constantly photographing their trips, their everyday activities. ‘Hey, we’re eating here at Magnolia Table,’ and they take a picture of their food, and they go, ‘This is tons of fun.’ It’s almost like you’re on some kind of show to where you’re constantly having to demonstrate that things are going well.

And then sometimes there’s a lot of bullying that occurs on social media too. And I’ve seen a lot of girls, in particular, that are just really cruel to one another and say demeaning things. I think that adds a whole new layer of complexity that if you don’t somehow fit in with that group, there’s this tendency to feel down about yourself because a lot of your self-image is made when you’re younger, particularly the teenage years.

WACOAN: While we’re talking about kids, how can parents determine if a teenager is just moody and has been for a month or is she depressed? How can parents tell the difference there?

Horner: For the most part, there are three major components that you’re looking for, for any person, but particularly teenagers: sadness, emptiness and hopelessness.

So conversations that come up where, ‘Oh, I don’t even think I’m going to do this or this.’ Withdrawing from your friends, that’s a big kicker in teenagers. Now teenagers a lot of times withdraw just so they can do their own thing, and I understand that part. But particularly someone that was otherwise engaging and active with their parents and then suddenly he’s off by himself, or he used to go with these friends, but he hasn’t been out with his friends anymore or at least in the last two to three months. Sudden changes in activity like that.

Sudden changes in grades. Someone who’s been typically an A-B student, behaves well at school, suddenly is making Cs and Ds on a consistent basis. You have to say to yourself, ‘Why?’ Now sometimes it’s drug-related. Sometimes it’s depression-related. Sometimes it’s both. These are types of things we see just with pure depression.

And motor retardation is kind of moping around. Not getting up and riding your bike anymore or doing activities. So these are actually components. And I’ll tell you, for teenagers, thoughts of death, guilt and worthlessness, I think it’s really important for parents to have an account [on social media] to actually follow their children some. Because sometimes children, and particularly teenagers, will express themselves more with their peers and be open and honest.

As we look at various tragic situations, most of the time you can go back to the social media and go, ‘Huh, he said he was down. Huh, he talks about death. Huh, he talks that he’s worthless.’ A lot of times you can see those patterns.

And it’s important for parents not to be in denial. Sometimes we try to candy-coat it, but looking for these symptoms are very, very important. Withdrawal, sadness and sudden changes in grades or performance. Those are [important] subtle signs of early depression.

WACOAN: How do anxiety and depression differ?

Horner: Well depression is really kind of, it’s a sadness. It’s a lack of enjoyment of things that you used to enjoy. And it’s a hopelessness for the future.

Anxiety is, I’m on edge. You remember Barney Fife [from ‘The Andy Griffith Show’]? You remember when he’d get really nervous? That is the classic muscle tension and hyperarousal. You’re irritable, you’re on edge, you’re fearful. Everything has got an ulterior motive, and you’re concerned about everything because you want to make sure you control the situation.

There tends to be a little bit more edge to anxiety whereas depression in its purest form tends to be more of sadness and pulling away. But again, it’s important to note there can be mixtures of those, and sometimes it becomes confusing as to what is what.

WACOAN: What treatments are there for, say, anxiety?

Horner: It depends upon how it’s affecting you and your life. Sometimes it’s just a matter of talking through things. But for those people which that’s not enough, there are counselors and psychologists. There’s particularly cognitive-behavioral therapy that can be very, very helpful.

Cognitive-behavioral therapy is more about allowing you to relook at the same problem in a different way. It’s almost like, here’s the situation, but now you put on a new lens and go, ‘Oh, well if I just stay away from the edge of the mountain, I’m not going to fall off of it, am I?’

So the thing is that it’s an approach and a framework. It’s called reframing of how you look at life. And there are certain counselors that are very skilled at helping people develop the tools to be able to look at life. The earlier that’s intervened in life, generally the better that people do.

There are eye-directed therapies as well, which are fascinating. [Psychologist] Betty Devers does this here in town. It happens after major trauma that I’ve found this to be very helpful, for [post-traumatic stress disorder], which is kind of in the genre of anxiety.

But you know when you’re telling a story, sometimes you can’t remember the details, and you’re looking around? What you’re doing is actually looking for areas within your brain to retrieve those memories. So that therapy, in a nutshell, uses eye movement to help track hidden memories — some are traumatic memories — and bringing those to the forefront because when they’re not dealt with, many times they create an underlying storm in your life. And you didn’t really know that that’s what was bugging you.

I think the biggest treatments for anxiety — we now know through functional MRIs — they literally change the brain. So the brain function and the tracks that lead to the limbic system can be erased away within one or two years and reestablished with new tracks in the brain and a new way to look at things. It literally changes the limbic system and how it interacts with you.

Then medications are another [treatment option] as well.

WACOAN: Are treatments for depression similar to that?

Horner: Depression can be multifactorial, and a lot of times it depends on the depression. Sometimes depression can be situational. Sometimes it can be related to pure hormonal changes too.

Medications to treat anxiety and depression actually can be fairly similar. The SSRIs, which affect serotonin — serotonin reduces the hyperactivity level in the limbic system for anxiety, but it also increases levels in other parts of the brain that are in control of emotion and happiness. So it can have a dual effect. And that’s why SSRIs or SNRIs are used commonly for people that have mixed depression and anxiety because you kind of take care of two things with one medicine.

And it’s not habit-forming. It can never be habit-forming because you’re not giving them something they don’t make. You’re just blocking certain receptors, allowing the serotonin or norepinephrine dopamine to rise, in order to get to appropriate balance again.

WACOAN: I’ve heard stories of people who have a family member with depression, and their advice to them is to get over it or just cheer up. I assume that’s not a good way to approach that. So if you have a family member dealing with depression, what can you do?

Horner: I think the first thing is listen to them. Because I think in the old days before there was any help, whether it be counseling or medication or otherwise, life was hard. Sometimes you just had to pull yourself up by your bootstraps, [to use] a Texas phrase. Some folks back then said, you’re just going to have to get over it.

But now we know that there are certain things that can be done. And medications and counseling have been improved to the point of earlier recognition, earlier treatment and, in many cases, remission. Remission is this notion of the human brain changing so much that the symptomatology fades away. In fact, we try to treat to remission. Kind of sounds just like cancer therapy. You wouldn’t play around with cancer and say, ‘Oh, let’s just treat it a little bit.’ You’d say, ‘No, I want remission,’ and the same thing goes for the human brain.

These are things we just learned in the last 10-15 years. The science is exciting because PET scans and functional MRIs allow us to see the inner workings of the brain in ways that we’ve never been able to see before and how counseling works in the human brain and how medications [work]. And it turns out, both together, in many cases, play a significant role in changing it.

So the notion of, just get over it, some people think that’s the way their life’s going to be, and they either get horribly depressed and commit suicide or use other alternatives like illicit drugs to try and feel peace of some kind. That’s when we get in a lot of trouble, by ignoring it or, worse yet, putting a person down that, ‘Gosh, you just need to be tougher.’ Then you start seeing it as a character defect, and in reality, it’s much more [going on]. It’s not a character defect.

WACOAN: When people come to you, do they come to you and say, ‘I’m having anxiety,’ or ‘I’m having depression?’ Or do they come to you with some other problems and then you discover, oh, you’ve got this, and you’ve got this?

Horner: E, all of the above. And I’ll tell you, add another layer to that. We’re now starting to screen people during their visits for like, let’s just say, a checkup. I’ve had two people where I didn’t see it. And I even just had to tell them, ‘I’m so sorry. How long have you lived with this? I didn’t know.’

WACOAN: With anxiety or depression or both?

Horner: Both. One was horrendously depressed and somehow, someway he just worked around it. So he didn’t come in with those complaints. The screening that we’re doing now, like these questions, are a way in which to unearth those people that you just don’t know about.

You know, Henry David Thoreau said most men live their lives in quiet desperation. I believe that’s true for a lot of folks, and sometimes that quiet desperation can take the form of depression and anxiety. Whatever we can do to try and help people recognize that you’re going to be OK, and we have ways in which to help you, and we won’t quit. We won’t quit until you’re doing better.

WACOAN: You said ‘ways to help.’ Are there nonmedical ways to help? Therapy, exercise, mediation, prayer?

Horner: Yes. Yes, yes, yes and yes. The thing is, is that exercise changes brain chemistry. We now know that mild to moderate forms of depression can be markedly improved with exercise. So aerobic exercise will stimulate serotonin or epinephrine and particularly dopamine. And there are many people that exercise on a regular basis that it really helps reduce their depressive symptoms.

Meditation is critical. I think meditation is probably the most underutilized nonmedicinal form out there. And I think meditation takes the form of a variety of ways. We a lot of times think of, you know, the Zen, making the sounds and that sort of thing. But really meditation goes back to Christianity as well. Jesus meditated as well as prayed.

Meditation is a way to clear your mind of all the clutter. Sometimes I listen to white noise. Sometimes I’ll listen to sounds of waterfalls. Things like that relax me, and it’s a way to clear your mind. I believe God designed us to meditate, not ruminate. Rumination is constantly getting in this loop and ruminating about the same issues and same problems.

A lot of times that will happen in the middle of the night. You’re sleeping great. All of the sudden, it’s 3 in the morning, and that thing you’ve been worried about you start ruminating on, and you can’t shut your mind off. You keep going, you slice it and you dice it a thousand different ways. But nonetheless, it has activated you in the middle of the night, and you tend to ruminate over it.

I believe that meditation can not only be working with your breathing, which is really critical to slow the physiological component down of panic attacks and anxiety, but I also think meditation can be used in the form of reciting — as a Christian — reciting Scripture. A lot of times, I’ll go to Psalms. ‘I will not fear bad news. My heart remains steadfast and I will trust in you.’ [from Psalm 112:7]. And that’s my prayer. That’s my meditation.

Even Jesus talked about anxiety. He said, ‘Who amongst you can add one hour to your life by being anxious.’ He said, ‘If you can’t control even that, why worry about the rest?’ That’s in Luke [12:25-26].

So from a mental, physical and spiritual aspect, meditation and prayer, I believe, can have an enormous effect on how people adapt to stressors in their life and how they adapt to anxiety. They have in my life. They’ve made a big difference.

WACOAN: Can diet play a role?

Horner: Absolutely.

WACOAN: How so?

Horner: Certain foods can create dysregulation in the human body and create an inflammatory state in the human body where we have to be careful because comfort foods — you don’t want a bowl of cauliflower when you need comfort. You need chocolate. The thing is, is that those comfort foods change brain chemistry.

WACOAN: Really?

Horner: They change brain chemistry. Chocolate has an enormous effect on dopamine in the brain. So chocolate, as an example, affects brain chemistry.

Now dark chocolate can be helpful, but milk chocolate tends to be hazardous to health over time. What we find is certain foods can create an inflammation in the body as it changes [to] visceral fat in the midgut. There’s lots of different things looking at that right now.

Certain foods and certain habits like caffeine can also markedly increase anxiety because caffeine itself works on an enzyme called COMT in the brain that breaks down norepinephrine and epinephrine. Well that’s what’s increased when you’re stressed. So it blocks the breakdown and allows the levels to rise.

A lot of people are drinking tons of coffee or diet Coke or energy drinks because they didn’t sleep well at night, and they’re wired for sound. So a lot of folks will have insomnia at night, and they describe it as ‘wired and tired’ because the brain is so hypervigilant. That’s another term that we see both with anxiety and PTSD is a hypervigilant state of the limbic system.

So food plays a huge role. Certain additives like nicotine, alcohol, etc., play a huge role too in the brain chemistry.

WACOAN: You kind of touched on this. Can sleep deprivation heighten or cause anxiety or depression?

Horner: Yes, yes.

WACOAN: How does that work?

Horner: You know, in ways we don’t clearly understand. There’s a restorative and renewing effect in human sleep, in deep sleep, stage 4 of REM. There are five different components, stage 1 through 4. [Stages] 1 and 2, very superficial. It’s like, ‘Oh, it would be easy to wake up.’ [Stages] 3 and 4 are much deeper and have restorative changes, and REM sleep, dream sleep, has also restorative changes too and neural hormone productions and various things like that.

Sleep, even though we do it at least a third of our life, we still don’t understand as much as we need to. But it has a very unique component on how the brain functions, and for whatever reason, we need rest in order to rejuvenate us and help create those neural hormones for the day that play a role both in anxiety and depression too.

WACOAN: So you get yourself into a cycle. Lots of caffeine during the day, can’t sleep at night. Then you’re tired the next day, so more caffeine gets you going. And then, like you said, wired and tired the next night.

Horner: I see it all the time.

The other flip side that I see with some people who can’t sleep good, they drink a bunch of booze before they go to bed, which kind of knocks them out. But it starves you of deep restorative sleep, and it creates this [same] vicious, negative cycle. Now I’m seeing in teenagers and college students, they’re telling me, ‘Hey, Dr. Keith, I’m smoking a little weed before I go to bed because that’s the only thing that gets me to sleep.’

So there’s this hodgepodge of ways to adapt to what’s going on, [but] they create other unintended consequences down the road.

WACOAN: Do you see anxiety and depression more in men or women?

Horner: I think women for the most part. If you look at the statistics, there is a higher amount reported in females. However. However, I believe females are better at talking about their feelings than men. There, I said it. It’s out there. They just are. They’ll share with me what’s going on.

We, as men on the Y chromosome, somehow it’s not considered macho to be talking about depression and anxiety. That means I’m ‘less of a man’ in my mind. And men aren’t real good about going to therapy. Men aren’t real good about taking medication.

Now I say this in general. I mean, I have a handful of men that do very well and function extraordinarily, compliant, do the right things. But for the most part, men don’t want to talk about this. This is just too kind of psycho-like. A lot of them are hurting badly. A lot of them are drinking themselves into oblivion. A lot of them do all sorts of things to adapt to what seems to be overwhelming, but they don’t tend to tell me as much.

So when we say, is it more common in females than men, well the statistics show that it is. But I personally believe, just me, that women are more apt to say, ‘I need help.’ They’re better at expressing their feelings than men. That’s just my observation.

WACOAN: So people battling depression, can they still operate on a day-to-day basis, or are there varying degrees of depression where people still operate on a day-to-day basis? Or for some, is it just debilitating?

Horner: Yes. It’s every spectrum you can ever imagine. Some are severe to the point where they long to end their life, and for me, that’s the saddest of all.

Some folks go on in their life and compensate in ways that are maladaptive, and yet somehow they make it through. But there’s living, and then there’s thriving. There’s surviving, and then there’s thriving. And so, so many of these folks when you dig down have been depressed for years and somehow worked around it. They’re just surviving. They don’t feel the joy in life. They tend to get more of a pessimistic attitude on the future because, again, they’re kind of hopeless for the future.

The Bible even says the people who [don’t] have vision shall perish [Proverbs 29:18]. That just means you can’t have hope for the future, and you can’t see that future, and you can’t see yourself in it. I think you just end up surviving.

WACOAN: Can folks go in and out of depression, like there’s a season of depression and then, I don’t know if ‘bounce back’ is the right phrase, but just ease out of it?

Horner: There can be. It can occur, the most popular component would be seasonal affective disorder, like you see in places like Seattle. We know that sunlight plays a role. There are some studies now actually using light therapy. And in places like Seattle, they do use light therapy. It changes brain chemistry in ways we’re just now starting to understand.

We also see that hormonal cycles, particularly in females, premenstrual dysphoria disorder, and they primarily have it a week before their period. So we know that hormonal changes can influence brain chemistry, and there are two medicines —Prozac and Zoloft — that have the capability with just pure [premenstrual dysphoric disorder] that you can actually treat during that time in which to balance the hormones.

But the other thing, cycles of life. What I’ve noticed is in menopause in women or andropause in men, men a lot of times lose their identity when they quit working. They were always a principal, [or] they were always a teacher. They were a football coach, and they lose that identity because they found their identity in what they did. And many of them will go through phases of depression.

In fact, the elderly and the teenagers have some of the highest levels of depression and suicide. And that’s why we screen folks 65 and greater on a regular basis to find out, where are you, because of their situation, some have lost their spouse. Many of their friends have even moved on or passed away, so they’re isolated, many folks. It’s a situation where many of them become very, very depressed.

So that phase in life of retirement, particularly for men, can be devastating. That’s why it’s important as families to at least touch base with mom and dad. You know, they’re getting older. And like a John Mayer song, they’re only good at being young [from ‘Stop This Train’]. So they’re going through a point in life where there is a tendency, some people just get damp. We call it ‘get the blues.’ But depression really is more deep-seated, more persistent and tends to change the social and functioning capabilities of people. And that’s when we see it reflected on the testing as well.

WACOAN: You said seasonal. It might just be legend, but I’ve heard that suicide is highest around Christmas and holidays.

Horner: I believe that.

WACOAN: Why do you think that is?

Horner: It would be pure conjecture on my standpoint. But what I’ve noticed over the years is when you’re sad and lonely and depressed, and when others around you may be miserable, you don’t feel as bad that you don’t have all that. When others around you seemingly have it all together and you don’t, there’s just this hollow emptiness inside you.

As I’ve talked to folks, I see more people between November 25 and Christmas for depression and anxiety than any other time of the year. And almost to a person, even though they may not articulate it in that light, I think they sense more of an emptiness because there’s so much joy and happiness and frolic around them — home, family, people getting together.

To me the saddest thing is if you don’t have any place to go for Christmas. That tears me up. Because as a human being, we’re made to live in community. And a lot of people, they may not go home, or they may not have that family network. They may not have those things that a lot of us take for granted. And I think it’s during those times that they feel the greatest hopelessness, sadness and emptiness in life, and it’s because of the contrast in what’s around them during that time.

WACOAN: As a primary care doctor, do you provide care for your patients with anxiety and depression mostly, or do you tend to send them to specialists?

Horner: Well I probably will see at least 90 percent of all the folks from a medicine standpoint. There’s probably 5 to 10 percent that I’m having to send to the psychiatrist because of the degree of depression or other comorbid issues such as bipolar [disorder], schizophrenia. Issues such as that I believe are better treated by a psychiatrist.

Now on the issue of involving other specialists, I don’t include psychologists and counselors as other specialists. I do that on a regular basis. Because we want people to develop tools on how to look at life. And if we can enable them, we know through the studies that counseling and medication together are more powerful than either one by themselves. So I use the counseling and psychology specialists on a regular basis.

WACOAN: What else do I need to know that I haven’t asked about anxiety or depression?

Horner: I think these are the main things. It’s an issue. It’s a problem. It’s increasingly prevalent.

I think as we see various disasters happen around the nation, a lot of times we look back and go, ‘Oh my gosh, he was depressed.’ Or he may have had a deeper psychiatric issue. But I think being in tune with one another, particularly with loved ones and friends, if you see these signs and symptoms, talk to them. Try to do everything you can to befriend them. And certainly, there are folks that don’t seem to be ‘snapping out of it’ or ‘pulling themselves up by their bootstraps,’ and encourage them to get further help, whether it be by their primary care doctor, a counselor, or a pastor, a priest, or someone that has seen this before and can encourage them to get the help that they need.

WACOAN: So far, you’ve quoted the Bible, Henry David Thoreau and John Mayer. Are you reading anything good right now?

Horner: I am. Well, every day I read ‘Jesus Calling,’ by Sarah Young. It is the best devotional I’ve read in my life. I also read Henri Nouwen on a regular basis. He’s my favorite Christian author. I just got done with [his] book ‘Return of the Prodigal Son,’ and it’s a beautifully written book. I also finished reading, because my daughter is dating a boy who said this is a great book, it’s called ‘Wild at Heart’ by John Eldredge. And it’s fantastic. I thought it was very well done.

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