Depression, or major depressive disorder (MDD), is a mental health condition that affects millions of people all over the world and can be quite debilitating for those who suffer from it. Feelings of melancholy, hopelessness and helplessness are common symptoms of depression. Other symptoms include changes in sleep and eating habits, loss of interest in things that were once enjoyable, decreased focus and decision-making and diminished sexual desire. Fortunately, depression is a disorder that can be treated, and individuals who are struggling with this condition can choose from a variety of treatment options. In this article, Dr. Zeeshan Faruqui, Director of Interventional Psychiatry at Keystone Behavioral Health, discusses some medication and interventional treatment options.
Medication
Medication is one of the most common treatments for MDD, and is often the first option recommended by medical professionals. There are several different types of antidepressants and each work in different ways. Depending on the person being treated and their specific genes, some types of medication may be more successful than others.
The most widely-used antidepressants are selective serotonin reuptake inhibitors (SSRIs), which function by elevating serotonin levels in the brain. Serotonin is a chemical messenger in your brain that helps to regulate mood, and an increase in serotonin has been shown to reduce the severity of depressive symptoms. Examples of this type of antidepressant include: fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro).
Another type of treatment is serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications are similar to SSRIs as they increase serotonin levels. However, in addition to this, they raise the levels of norepinephrine which affects the body’s response to stress and can have an influence on mood. SNRIs include medications such as venlafaxine (Effexor) and duloxetine (Cymbalta).
The tricyclic antidepressants (TCAs) are an older class of antidepressants that raise serotonin and norepinephrine levels. Because of the greater likelihood that they will cause unwanted side effects, they are not prescribed as frequently as SSRIs or SNRIs. Examples are Amitriptyline (Elavil) and nortriptyline (Pamelor).
In addition, there is an earlier class of antidepressants known as MAOIs, which stands for monoamine oxidase inhibitors. Monoamine oxidase is an enzyme that can remove serotonin and norepinephrine from the brain, and this type of medication prevents them from being removed. However, MAOIs are not commonly recommended as there can be dangerous interactions between them and other types of drugs, and even particular foods. Phenelzine (Nardil) and tranylcypromine (Parnate) are two examples of MAOIs.
Antidepressants can be very effective, but there is a risk of unwanted side effects such as nausea, headaches and dizziness. There is also the possibility of more serious effects, such as an elevated suicide risk, especially in younger people like children and young adults. Patients who are taking antidepressants are regularly monitored by medical professionals to ensure that they are responding well to treatment and are not suffering from any negative side effects.
GABA Pathway Medications
Gamma-aminobutyric acid, also known as GABA, is a neurotransmitter that works to maintain a stable mood and reduce anxious feelings. A number of antidepressants work by targeting a particular circuit in the brain called the GABA pathway.
Brexanolone (Zulresso), one of these medications, has been given the go-ahead by the U.S. Food and Drug Administration (FDA) to treat postpartum depression (PPD). It is a steroid that boosts GABA’s activity, and is a synthetic version of allopregnanolone, which is naturally made by the body. Clinical trials show it can quickly reduce depressive symptoms in women who have PPD.
Ketamine is another type of medicine that works by targeting the GABA pathway. It has been used in medical settings for decades, and in recent years has been shown to be an effective treatment for depression. Even in patients who have not had good results from other treatments, clinical trials show ketamine is able to quickly improve their depression symptoms.
Neuroactive Steroids
Neuroactive steroids belong to a class of hormones known for their influence on the central nervous system as well as the brain. They have the potential to impact one’s mood, level of anxiety and response to stress, and certain neuroactive steroids can be useful in the treatment of depression.
Pregnenolone, a hormone that can be found in the GABA pathway, is one example. The body makes its own pregnenolone, but some people may benefit from increasing their levels. It has been proven in controlled clinical trials to be effective at relieving depressive symptoms in patients diagnosed with MDD.
Dehydroepiandrosterone (also known as DHEA) is another neuroactive steroid. DHEA is a hormone that plays an important role in the creation of other hormones, such as testosterone and estrogen amongst others. Studies conducted on both humans and animals have indicated that exposure to DHEA can have an antidepressant impact. Clinical trials show it can alleviate symptoms of depression in patients diagnosed with MDD.
Other Interventional Treatments
We are now in an era of psychology that involves taking action. Interventional psychiatry uses methods that stimulate the brain or fast-acting drugs to treat symptoms that aren’t getting better with regular medication and/or therapy. Clinicians use a lot of different methods to treat patients, but the ones I’m going to talk about below have been approved by the U.S. FDA, which means they are safe and work. These treatments have demonstrated encouraging results in treating depression, postpartum depression, and other conditions.
Transcranial Magnetic Stimulation
Transcranial Magnetic Stimulation (TMS) is a non-invasive treatment that is used when medicines aren’t working well or are causing side effects. TMS is done by putting a magnetic coil on the patient’s head while they are awake and aware. The treatment is not painful, and people can go back to their normal lives right away. Compared to medicines, TMS has very few side effects and most people who do have them say they are mild and only last a short time.
At my practice we currently offer TMS for those with major depressive disorder, but we hope to also offer this treatment for migraines and obsessive-compulsive disorder in the near future. I believe TMS can have a very positive effect on society, because it can treat a variety of disorders that impact many people’s lives. After studies are finished, it may also be available for those with PTSD, tobacco use disorder, alcohol use disorder and opiate use disorder.
Electroconvulsive Therapy
Another treatment is electroconvulsive therapy (ECT), in which the patient is given anesthesia and a small electrical current is then passed through their brain. This procedure is typically reserved for patients who have not reacted well to other therapies or who have severe symptoms. It is a very effective treatment and works quickly, but there can be side effects including memory loss.
This treatment has gotten a lot of bad press in the media and some movies. It is sometimes referred to as “shock therapy” and in the past was done without anesthesia. Today, ECT is much safer and is one of the best ways to help those with severe depression, including those who have psychosis or suicidal thoughts.
Vagus Nerve Stimulation
In this treatment, a device is implanted into the body which sends electrical signals to the vagus nerve – one of the nerves that connects the brain to the rest of the body. These implants are currently FDA-approved to treat epilepsy and sadness. When the device is turned on, it sends electrical signals down the nerve to the brainstem. The brainstem then sends signals to parts of the brain that are involved in sadness. The amount of energy can be changed based on what a patient needs. In Europe, doctors have cleared new devices that stimulate the vagus nerve without surgery. These devices can be used to treat epilepsy, depression and pain. In the United States, cluster headaches can now be treated with a device that triggers the vagus nerve without any surgery.
Neurosurgical Interventions
In the past, surgery was sometimes used for serious and debilitating cases. Today, neurosurgery is being used more and more to help people with mental illnesses. These treatments are much less invasive than those in the past and are also much more focused. Deep brain stimulation is a well-known and FDA-approved treatment for people with movement disorders like refractory epilepsy, essential tremor, Parkinson’s disease and dystonia, as well as for mental conditions like obsessive-compulsive disorder. Even though deep brain stimulation is thought to be safe, there is always a chance that something could go wrong, and stimulating the brain can have its own side effects. Deep brain stimulation includes making small holes in the head to put the electrodes in and surgery to put the battery-powered device under the skin in the chest.
External Trigeminal Nerve Stimulation
External Trigeminal Nerve Stimulation (eTNS) is the most current FDA-approved treatment for ADHD in children ages 7 to 12. This is the first way to treat ADHD without using drugs, and is meant to be done at home while being watched by an adult. It uses a device about the size of a cell phone which sends a low-level electrical pulse through a small patch that sticks to the patient’s forehead. This is not painful and the patient should only feel some tingling of their skin. It uses low-level electrical stimulation to send messages to the parts of the brain thought to be involved in ADHD. Even though we don’t know exactly how eTNS works yet, studies have shown that it boosts activity in parts of the brain that are important for controlling attention, emotions and behavior. For this to be suggested, you should talk to a mental health professional.
Conclusion
Major depressive disorder is a complicated medical illness that needs to be treated using a variety of different strategies. People who are struggling with depression can benefit from effective treatment options including medications, interventional psychiatric methods, medications that target the GABA pathway and neuroactive steroids. Together with their patient, healthcare professionals determine the most appropriate method of treatment by considering the patient’s specific biology, symptoms and treatment preferences. Patients diagnosed with depression have the potential to experience significant improvements in both the severity of their symptoms and their quality of life when given the appropriate treatment.
This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.
To learn more about Keystone Behavioral Health, call or text us at 717-709-7930 or visit our website.
