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New antidepressants can quickly lift depression and suicidal thoughts, but don’t expect magical cures
Depression is the most common cause of disability in the world. There is a good chance that you or someone you know will experience a period in which depression impedes work, social life or family life. Almost two out of three people with depression will have severe effects. As a psychiatrist specializing in behavioral neuroscience, I help patients with mood disorders. Many have “treatment-resistant” depression and are in an almost constant search for relief. There have recently been some interesting developments in the treatment of depression, especially the new fast-acting antidepressants. But it is important to understand that these drugs are not remedies. New treatments for depression promise to relieve painful symptoms, including suicidal thoughts, faster than any previous treatment. These include ketamine, an anesthetic that is also abused as a street medicine, and a ketamine derivative called esketamine. These medications have been shown to help relieve the symptoms of depression in a few hours, but each dose only works for a few days. They also present risks, including the potential for drug abuse. With the coronavirus pandemic affecting mental health, patients are looking for quick relief. Medication can help, but for the effective treatment of long-term depression, through its mixture of biological, psychological, social and cultural components, not only drugs are needed. Depressed Medications Evolved Early history of depressive treatments focused on the psychological components of the disease. The goal in the early twentieth century was for a patient to understand the unconscious needs established during childhood. The biological treatments of that period seem frightening today. These included insulin coma therapy and the primitive, often misused versions of a modern life-saving procedure – electroconvulsive therapy. The first drugs were sedatives and antipsychotic drugs. Chlorpromazine, marketed as “Thorazine”, led the way in the 1950s. In 1951, imipramine was discovered and will become one of the first antidepressants. The blockbuster antidepressant Prozac, a selective serotonin reuptake inhibitor or SSRI, was approved in 1987. It’s been over 30 years since we saw a new class of antidepressants. This is one reason why fast-acting antidepressants are interesting. Medical treatment for depression affects certain processing cells in the area of the brain above the eyes and under the forehead. This area, called the prefrontal cortex, processes complex information, including emotional expressions and social behavior. Brain cells called neurons are chemically controlled by two opposing messenger molecules, glutamate and gamma-amino-butyric acid (GABA). Glutamate works like a gas pedal, and GABA is the brake. These tell neurons to accelerate or slow down. Rapid-acting drugs for depression lower the action of glutamate, the gas pedal. Other treatments for GABA rebalancing have been developed. A neurosteroid called allopregnanolone affects GABA and acts as a brake. Both allopregnanolone and esketamine have federal approval for the treatment of depression, allopregnanolone for postpartum depression and esketamine for major depressive disorder and suicidal thinking. Not so fast Around 2016-2017, young psychiatrists like me rushed to implement these new antidepressant treatments. Our training supervisors said, “Not so fast.” They explained why we should wait to see how the new drug studies come about. A few years earlier, the medical community had experienced a similar enthusiasm for Vivitrol to treat opioid addiction. Vivitrol is a monthly injected form of naltrexone, a drug that blocks opioids. Clinical trials are performed in a very controlled and clean environment, while the real world can be extremely uncontrolled and very messy. Without risk reduction, education and psychosocial treatment, the potential risks of medicines such as Vivitrol can be increased. Vivitrol can help reduce recurrences, but it is not a panacea alone. The National Institute on Drug Abuse recommends integrated treatment for addiction. Treating depression can be similar. Medication and psychological support work better together than one. In depression, the more treatments a person tries that do not work, the less likely it is that the person will be successful with the next treatment option. This was a key message of the largest clinical trial of depression drugs, the STAR-D study, led by the National Institutes of Health, completed in 2006. Providing a more effective option for patients not responding to the first or second antidepressant you can turn that STAR-D message on your head. However, when treating a disease that is affected by external stress, such as trauma and loss, treatment is more likely to be successful with both medication and psychological support. A real-world approach to treatment called the biopsychosocial paradigm explains the wide range of relevant biological, psychological and social components of mental illness. The patient and the doctor work together to process the patient’s problematic experiences, thoughts, and feelings. A hyperfocus on new drugs may overlook the importance of addressing and monitoring all of these components, which could mean that problems arise in the future. Medicines such as opiates or other substances that provide rapid relief from physical or psychological pain may also be physically and psychologically addictive, and new fast-acting antidepressants may have the same risks. Rapid-acting antidepressants may be powerful tools for treating major depression when used with other forms of therapy, but are they the answer? Not so fast.[Get facts about coronavirus and the latest research. Sign up for The Conversation’s newsletter.]This article is republished from The Conversation, a non-profit news site dedicated to exchanging ideas from university experts. It was written by: Nicholas Mischel, Wayne State University. Read more: * COVID-19 could lead to an epidemic of clinical depression, and the health care system is not prepared for this, even as education and their incomes increase Nicholas Mischel receives or has received funding from American Heart Association, National Institutes of Health and Wayne State University. He is employed by Wayne State University and a member of the American Psychiatric Association, Society of Biological Psychiatry, North American Neuromodulation Society, Clinical TMS Society and American Society of Ketamine Physicians, Psychotherapists & Practitioners.