It wouldn’t be an overstatement to suggest the field of mental health is experiencing a renaissance. The rise in cases of major depressive disorder and treatment resistant depression has sparked real professional interest in alternative treatment methods, with subsequent mainstream adoption. By alternative, we refer to methods other than the prescription of the pharmaceutical drug classes historically used to treat depression: selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants (TCAs).
Treatment resistant depression, or TRD, is in fact defined by its resistance to these drugs; a patient is said to suffer from TRD if they do not show substantial improvement after full courses of two or more of the commonly prescribed depression medications.
SSRIs, SNRIs, MAOIs, and TCAs are the default medical treatments for major depressive disorder. All four trace their origins to medical advancements in the mid-20th century. They remain the standard of treatment, especially SSRIs, the most commonly prescribed class of antidepressants in most developed countries. While the efficacy of traditional antidepressants in a majority of treatment scenarios is clear, so too is the fact that our understanding of psychology, mental health, and neurochemistry now allows us to better address those cases that do not respond to such treatment with alternative therapies.
Alternative medical approaches
A number of alternative medications have existed alongside and in conjunction with the four primary classes of antidepressants for some time, prescribed in cases of treatment resistant depression. Examples include lithium, benzodiazepines, and stimulants. The level of popular enthusiasm in regards to these drugs, or lack thereof, should indicate their apparent usefulness in remedying TRD.
In recent years, however, new medical treatments have emerged into the mainstream following successful studies and trials. Easily the most impactful and fully realised of these is ketamine. The clinical use of ketamine in cases of TRD has quickly become a hot topic, the subject of glowing review by patients and therapists alike. Used for decades as a tranquilizer and anesthetic — with its psychiatric usefulness noted early in its development, but largely ignored — ketamine has now enjoyed several years of commercial success and recognition as an effective depression medication, withTRD patients often reporting near instant relief and few, if any, lasting side effects.
The ideal delivery of ketamine is done most often intravenously, under the supervision of a licensed ketamine technician. Technicians act as both chaperone and coach during a ketamine experience, particularly helpful to those inexperienced with the procedure. The FDA has approved ketamine in a modified form, esketamine (under the brand name Spravato), which is distributed as a liquid solution and delivered nasally via spray bottle. According to Dr. Fahimian, who treats patients with ketamine and other alternative therapies, treatment is most effective when combined with traditional cognitive behavioral therapy and a holistic approach.
Further out on the horizon is psilocybin, the active chemical produced naturally by mushrooms of various genera, such as those in the genus Psilocybe. Preceded by a rich and controversial reputation, psilocybin — actually a prodrug of psilocin, its metabolized, active counterpart — now enjoys FDA Breakthrough Therapy Designation, authorizing its legitimate use in TRD treatment studies and trials. Fully authorized research programs investigating the psychiatric efficacy of psilocybin now operate at prestigious universities worldwide, such as Imperial College London, University of California at Berkeley, and Johns Hopkins University. It is likely we’ll see psilocybin enter the marketplace as a legitimate psychiatric medication within the next decade, in a similar vein to ketamine’s application.
Non-medical treatments, or physical treatments, are a popular subject among patients and doctors burnt out on medication. These physical depression treatments most commonly take the form of electrical stimulation of the brain.
The oldest form of therapeutic electrical stimulation is electroconvulsive therapy, or ECT. ECT has a stigma due to some side effects, and is used as a last resort in the most serious of cases. ECT instruments, like many other forms of treatment, are strictly regulated in most jurisdictions.
ECT paved the way for exploring the role of electricity in brain health. With a notable decrease in frequency of ECT’s casual use during the 1970s, new methods of electrical stimulation entered the experimentation phase. In 1985, following breakthroughs in implant-based electrical stimulation treatments, the first transcranial magnetic stimulation (TMS) devices were finalized, allowing for the non-invasive delivery of electromagnetic pulses which alter neuron function in the brain. The frequency and number of these pulses is dependent on the type of TMS treatment employed.
TMS therapy is now recognised as the preeminent non-invasive treatment for TRD, with a success rate between 70% and 80%, and a 50% rate of complete remission. Those averse to traditional depression medications or unsatisfied with the performance of those medications, and uneasy about alternative medical treatments such as ketamine therapy, can consider TMS treatments.
Adam Mulligan did his degree in psychology at the University of Hertfordshire. He is interested in mental health, wellness, and lifestyle.
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