For the last several decades, treatment of depression consisted of either anti-depressant medications or psychotherapy or some combination of the two. The one exception was electro convulsive therapy or ECT, reserved for the most severe cases of depression in which someone might stop eating, be completely unable to function, or be acutely suicidal. More on this treatment later.
Research studies show response rates to antidepressants ranging from 40% to as high as 65%. Response means 50% improvement, not 80 to 100% better. That means 35-60% are not even 50% better. Remission rates, which means the depression is fully treated, for antidepressants are estimated between 25 and 30%.
The bottom line? There are many people taking antidepressants who are either not better or only a little better. Add to this the fact that many people suffer intolerable side effects with anti-depressants. These may include weight gain, sexual problems, effects on memory and concentration, insomnia or excessive sleepiness… just to name a few.
Now don’t get me wrong. I’m a great believer in the effectiveness of anti-depressants, and when depression hasn’t responded to non-medication treatments such as lifestyle changes and/or psychotherapy, I strongly recommend and prescribe them. My patients may have to try a few of them before they find one that work works the best for them and hopefully with few or no side effects.
But what happens if they don’t work or cause uncomfortable side effects? There has been a quantum shift in new treatment options for those who have not tolerated or have not responded adequately to standard antidepressant medications. This type of depression is often referred to as treatment-resistant depression or TRD. Unfortunately, not all psychiatric health care providers offer these different options. And if they do, many insurance companies put roadblocks to people from having access to these therapies because of the cost. However, the cost of not treating depression is much greater. Untreated depression can cause a breakup of families, loss of job, loss of quality of life, and sometimes even loss of life itself. Partially treating depression often in the work in the work or home place causes a phenomenon called “presenteeism” where simply because one is feeling “better“ -but not yet well-they are still expected to perform at the level they were when they were not having depression. This is a degree of pressure that can become overwhelming and demoralizing with devastating consequences.
ECT is one of the oldest and still used non-medication treatments available today and remains an option for those suffering from TRD. There are few places to receive ECT outside of a hospital and it can be quite inconvenient to find a doctor and facility that offers that treatment. Furthermore, ECT can have considerable side effects including memory impairment and the risks associated with being under anesthesia while it is being administered. As a result, this has often been reserved for the most severe cases of depression. Access, side effects, inconvenience, and, and an important “and”, the stigma associated with ECT from books, movies, and TV shows has had many people pass on this treatment option.
Ketamine, an old medication used in anesthesia and pain management, has been shown to be highly effective in TRD and is ushering a whole new era of treatments. Many of these treatments are still in development phase. They have a completely different mechanism of action from standard antidepressants. Ketamine helps the brain re-wire itself, form new neuronal connections and target a chemical in the brain called glutamate which plays a role in learning, mood, anxiety, and memory. Ketamine has been shown to help a number of people who have not responded or tolerated traditional anti-depressants. Because ketamine is not FDA approved for depression, insurance will typically not pay for it.
A new medicine similar to ketamine is now available called Spravato®. Spravato® is the only anti-depressant that’s indicated for individuals suffering with depression and suicidal ideation. It is also approved for TRD. It is a nasal spray and must be given in an approved and specially trained health care provider’s office. It is expensive, and consequentially insurance companies make it very hard to access this novel and highly effective therapy.
Even though Ketamine and Spravato® are still medications, they are only in your body at the time of administration and leave quickly due to their short half-life. Side effects are typically not experienced the day after you receive the medication. A completely non-medication treatment option is transcranial magnetic stimulation or TMS. A magnetic pulse is given at a very specific frequency and targeted at a very specific part of your brain. There’s no medication given at all. TMS has also been shown to be extremely effective in individuals who have not tolerated or responded to antidepressants.
When considering these alternatives, it’s best to get a psychiatric consultation from a health care practitioner who is fully trained in all of these modalities. Also consider seeing someone who actually administers all three therapies so as to not have your treatment suggestion biased by a health care provider who does not have all these tools in their toolbelt. Each of these treatments have their advantages and disadvantages… and their risk and benefits. Not one treatment is “the best” for anyone person.
If you or someone you love is suffering from depression and is not responding to traditional antidepressant medications, take the initiative to educate yourself about all the possible treatments out there and consult with a specialist in the area of treatment resistant depression. One, or maybe even a combination, of these new alternative therapies may put you or a loved one back on the road to recovery.
Author:
Medicine at the Emory School of Medicine in Atlanta. He completed his psychiatry residency at McLean Hospital, Harvard Medical School. Dr. Banov has conducted over 150 clinical research studies in all aspects of psychiatry, including anxiety, depression, bipolar disorder, and post-traumatic stress disorder (PTSD). He has written over 25 scientific papers and articles. Dr. Banov shares his experience and knowledge as an assistant clinical professor at the Medical College of Georgia.