There are many ways to treat depression, including talk therapy and antidepressants. But not everyone responds to these treatments the same way. About 1 in 3 people with depression don't get relief from their symptoms.
One reason why depression can be so hard to treat is that each person’s body and brain interacts differently to antidepressants.
"Right now, it's difficult to predict which particular drug may work best for which individuals," says David Mischoulon, MD, PhD, director of the Depression Clinical and Research Program at Massachusetts General Hospital. "We don't yet have a perfect treatment for depression, unfortunately."
That could change one day. People with depression, and the doctors who treat them, have good reasons to be optimistic. Antidepressants have improved over the years. And new drugs in the pipeline could give people with hard-to-treat depression another option.
Better SSRIs
Today, the first antidepressants that doctors often prescribe for major depressive disorder (MDD) are selective serotonin reuptake inhibitors (SSRIs) like these:
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
SSRIs have fewer side effects than older antidepressants. Because they’re so safe, it's easier to stay on them long enough to get the response you want, Mischoulon says.
Up to 6 out of 10 people who take SSRIs will see their symptoms improve within 2 months. The 40% who don't get better on these drugs will need to try other treatments.
Ketamine
Ketamine is a drug that's giving hope to treatment-resistant depression. First used as anesthesia during surgery, ketamine targets different brain chemicals than SSRIs. It works quickly to relieve hard-to-treat depression.
And ketamine may help if you don’t get relief from SSRIs. "It's particularly effective for some people who have not responded to most of the oral antidepressants," says Mischoulon. Ketamine also helps with severe depression and suicidal thoughts.
Spravato is a prescription nasal spray that contains a version of ketamine called esketamine. Because Spravato is FDA approved, many insurance plans will cover the cost. It's also available in an IV form that's not approved. Doctors sometimes use the IV form off-label to treat depression, but it may not be covered by insurance, Mischoulon says.
When used under a doctor's supervision, ketamine is very safe. The most common side effects are:
- An out-of-body feeling
- Dizziness
- Nausea or throwing up
- Sleepiness
- Numbness
- Anxiety
- Low energy
- High blood pressure
One downside to Spravato is that you can only get it at a doctor's office. And you have to stay there for a couple of hours afterward so the staff can monitor you for any problems. "This makes the treatment rather inconvenient for many people," Mischoulon says.
Other Depression Drugs on the Horizon
Auvelity is another new drug that works on the same parts of your brain as ketamine. It's a combination of the antidepressant bupropion and the cough suppressant dextromethorphan. One advantage of Auvelity is that it comes in a pill so you can take it yourself. But it doesn't work as well as ketamine.
"Auvelity can help some people, but we don't see the kind of dramatic effect that we see with ketamine," says Mischoulon. The goal is to one day develop pills that relieve depression as well as ketamine.
Other promising depression medicines that researchers are studying target opioid receptors in your brain. Those receptors produce the euphoric "high" you get with opioid pain relievers. The goal is to create a drug that boosts mood without causing addiction like opioids do. "If you could use the opioid receptors to elevate mood without the risk of addiction or abuse, you would really have a game changer drug, I think," Mischoulon says.
The Future of Talk Therapy
The most effective way to manage depression for the long term is with antidepressants plus cognitive behavioral therapy (CBT) or talk therapy. Just like medication, talk therapy has changed over the years.
A one-size-fits-all approach is being replaced by more personalized therapy methods. "For example, there's CBT for people with chronic pain. There's CBT for people who are dealing with grief or trauma," Mischoulon says. Therapists will continue to fine-tune this treatment to make it more targeted.
Reasons to Be Hopeful
It can be hard to live with depression. But anyone with a diagnosis should feel hopeful. "There are so many treatments available," says Mischoulon. Along with dozens of different antidepressants and ketamine, there's electroconvulsive therapy, transcranial magnetic stimulation, and a variety of talk therapies. "So really, there's reason to be optimistic because there's already a lot out there, and there are a lot of [therapies] that are being developed."
Partnering with a mental health provider you trust will help you manage your depression. Be patient. It can take 6 to 8 weeks for treatments to start working. Your doctor might need to adjust the drug or your dose along the way.
"I tell patients who are about to embark on an antidepressant treatment, 'Don't feel discouraged if you don't start to feel better right away. It's going to take time,'" he says.
If you think you're depressed, see your primary care doctor or a mental health provider for advice. Once you find the treatment that works for you, "It can make a tremendous difference in your life," Mischoulon says.
Show Sources
Photo Credit: iStock/Getty Images
SOURCES:
American Journal of Psychiatry: "Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation."
APA: "APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts."
Columbia University Irving Medical Center: "Understanding Ketamine Treatment for Depression."
FDA: "Highlights of Prescribing Information: Auvelity," "Highlights of Prescribing Information: Spravato."
Johns Hopkins Medicine: "Treatment-Resistant Depression."
Mayo Clinic: "Selective Serotonin Reuptake Inhibitors (SSRIs)."
National Library of Medicine: "Depression: How Effective Are Antidepressants?"
World Journal of Clinical Cases: "Major Depressive Disorder: Validated Treatments and Future Challenges."
