I Am Psychiatry is that if your depression doesn't improve after psychotherapy and antidepressants, the latest fast-acting medications are promising for treating depression that is resistant to treatment.
SSRIs are the most common and well-known antidepressants. These work by changing the way that the brain processes serotonin which is a chemical messenger.
Cognitive behavioral therapy (CBT) helps you to change negative thoughts and behaviours such as despair. It's available on the NHS for 8 to 16 sessions.
1. Esketamine
The FDA approved a new treatment for depression in March of 2019 which is a nasal spray dubbed esketamine (brand name Spravato). It is derived the anesthetic, Ketamine. This has been shown to be effective in cases of severe depression. The nasal spray can be used with an oral antidepressant in order to treat depression that hasn't responded to standard medications. In one study 70 percent of those suffering from treatment-resistant depression given the drug responded well -- a far higher response rate than with just an oral antidepressant.
Esketamine is different from traditional antidepressants. It boosts the levels of naturally occurring chemicals in the brain, known as neurotransmitters. They transmit messages between brain cells. The effects aren't immediately apparent. Patients generally feel better after a few days, but the effects last longer than SSRIs and SNRIs.
Researchers believe that esketamine reduces symptoms of depression by enhancing connections between brain cells. In animal studies, esketamine reversed these connections that can be broken down due to depression and stress. In addition, it seems to stimulate the development of neurons that could help to reduce suicidal ideas and feelings.
Another reason esketamine stands out from other antidepressants is the fact that it is delivered via an nasal spray which allows it to get into the bloodstream more quickly than a pill or oral medication could. The drug has been proven in studies to lessen depression symptoms within a couple of hours. In certain instances the effects may be instantaneous.
A recent study that tracked patients for 16-weeks found that not all patients who began treatment with esketamine had reached the remission phase. This is a bit disappointing, but not surprising, according to Dr. Amit A. Anand an expert in ketamine who was not involved in the study.
Esketamine is only available in clinical trials or in private practice. It is not considered to be a first-line treatment option for depression, and is typically prescribed when SSRIs or SNRIs have not worked for a person with treatment-resistant depression. A doctor for a patient can determine if the condition is not responding to treatment and decide if esketamine could be beneficial.
2. TMS
TMS uses magnetic fields to stimulate brain nerve cells. It is noninvasive and does not require anesthesia or surgery. It has been proven to aid people suffering from depression who haven't responded to medications or psychotherapy. It can also be used to treat obsessive compulsive disorder (OCD) and tinnitus.
For depression, TMS therapy is typically given in a series of 36 daily sessions spread over six weeks. The magnetic pulses feel similar to pinpricks that are placed on the scalp and can be a little difficult to get used to. After the treatment, patients are able to return to work or go home. Each TMS session can last between 3.5 minutes and 20 minutes, based on the pattern of stimulation.
Scientists believe rTMS works by altering the way neurons communicate with each other. This process, known as neuroplasticity, enables the brain to form new connections and to modify its function.
Currently, TMS is FDA-cleared to treat depression when other therapies like talk therapy or medication, have not worked. It has also been proven to aid people suffering from tinnitus, OCD and pain. Scientists are currently examining whether it can be used to treat anxiety and Parkinson's disease.
TMS has been shown to reduce depression in a number studies, however not every person who receives it benefit. Before you embark on this treatment, it's important to undergo an extensive medical and psychiatric evaluation. TMS is not a good option when you have a history of or a history of certain medications.
A visit to your doctor may be beneficial if you're experiencing depression but aren't experiencing any positive results from your current treatment. You may be a candidate to try TMS or other forms of neurostimulation but you need to try several antidepressants before insurance coverage covers the cost. If you're interested in learning more about these life-changing treatments, call us today for a consultation. Our experts can guide you through the process of deciding whether TMS is the right option for you.
3. Deep stimulation of the brain
For those suffering from treatment-resistant depression, a non-invasive treatment that rewires the brain's circuits could be effective in as little as a week. Researchers have developed new techniques that enable them to deliver high-dose magnetic impulses to the brain in a shorter time and at a frequency that is more adaptable for patients.
Stanford neuromodulation therapy (SNT), which is now available at the UC Davis Department of Psychiatry and Behavioral Sciences' Advanced Psychiatric Therapeutics Clinic utilizes MRI imaging to guide electrodes that send magnetic pulses to the targeted areas of the brain. In a study conducted recently, Mitra and Raichle found that in three-quarters (75%) of patients suffering from depression, the normal flow of neural activity from the anterior cingulate cortex and the anterior insula was interrupted. With SNT the flow of neural activity returned to normal within a week, which coincided with the lifting of their depression.
A more invasive technique called deep brain stimulation (DBS) may produce similar results in certain patients. Neurosurgeons perform a series of tests to determine the ideal place to implant one or more leads into the brain. The leads are connected to a nerve stimulator implanted beneath the collarbone, which looks like a heart pacemaker. The device supplies continuous electrical current to the leads, which alters the brain's circuitry and helps reduce depression symptoms.
Certain psychotherapy treatments can help relieve depression symptoms, including cognitive therapy for behavioral disorders and interpersonal therapy. Psychotherapy can be delivered in one-on-one sessions with a mental health professional, or in group settings. Some therapists offer online health.
Antidepressants are the mainstay of treatment for depression. In recent times, however there have been some notable improvements in the speed at which they can relieve symptoms of depression. Newer drugs, such as gepirone (Exxua), esketamine (Spravato), brexanolone (Zulresso) and dextromethorphan-bupropion (Auvelity), all have been shown to work faster than older antidepressants.
Other treatments, like electroconvulsive treatment (ECT) or repeated transcranial magnet stimulation (rTMS) utilize electric or magnetic stimuli to stimulate the brain. These are more complicated procedures that need to be performed under a physician's care. In some cases they can cause seizures and other serious adverse effects.
4. Light therapy
Bright light therapy, which involves sitting or working in front of an artificial light source, has been proven for a long time to treat major depression disorder through seasonal patterns (SAD). Studies show that it can relieve symptoms like sadness and fatigue by regulating the circadian rhythms and improving mood. It can also help people who experience depression that occurs and disappears.
Light therapy mimics sunlight, a key component of the biological clock called the suprachiasmatic nucleus (SCN). The SCN is linked to mood and light therapy has the ability to change the patterns of circadian rhythms that can contribute to depression. Additionally, light therapy can lower melatonin levels, and restore the neurotransmitters' function.
Some doctors employ light therapy to combat winter blues. This is a milder form of depression that is similar to SAD however it has fewer people affected and occurs during the times of year in which there is the least amount of sunlight. To achieve the best results, they recommend that you lie in front of the light therapy box for 30 minutes each morning while awake. Unlike antidepressants, which can take weeks to work and can cause adverse effects like weight gain or nausea the light therapy method can deliver results in just a week. It's also safe during pregnancy and in older adults.
Researchers caution against using light therapy under the supervision of a mental health professional or psychiatrist, since it can trigger manic episodes for people who suffer from bipolar disorders. It can also make sufferers feel tired during the first week of treatment as it could alter their sleep-wake patterns.
PCPs should be aware of new treatments that have been approved by the FDA however, they shouldn't neglect tried-and-true methods like antidepressants and cognitive behavioral therapy. "The search for more effective and innovative treatments is exciting, but we should continue to focus on the most well-established therapies," Dr. Hellerstein tells Healio. He suggests PCPs need to educate their patients about the advantages of new treatments and assist them in sticking to their treatment plans. That can include offering transportation to their doctor's office or setting up reminders to take their medication and attend therapy sessions.