Depression treatment has been in the news this spring, as a couple of new medications were announced, at the same time that reputable researchers challenged the effectiveness of well-established ones. This post summarizes these reports, and offers an historical perspective as well as discussing alternatives for treating depression.
First, the FDA approved Spravato (esketamine), a nasal spray for “treatment-resistant” depression. While some doctors welcomed this news, consumers, beware! Spravato is derived from the anesthetic drug ketamine, and a one-month treatment will cost from $4,720 to $6,785, according to the drug’s manufacturer. It’s anybody’s guess whether health insurers will cover it.
Ketamine has been around for a long time. Originally developed as an anesthetic, it became popular as a “party drug” due to its hallucinogenic properties. In recent years, some doctors have experimented with using it to treat depression, with mixed results. I have a few patients in my practice who’ve had this treatment; while one experienced remarkable results, the others did not.
Here’s what one of my colleagues had to say about Spravato:
“In the spirit of George Bernard Shaw’s advice (“Beware of false knowledge; it is more dangerous than ignorance”), I am writing to clarify information about the recently approved Spravato (esketamine), a nasal spray medication for depression. Given the incredible excitement amongst millions who are desperately seeking relief, expectations are high. While I am encouraged by intensive intravenous ketamine treatments, I fear that the FDA, drug manufacturer, and media are over-selling Spravato and failing to provide us with the necessary facts for an informed choice. For example, half of the clinical trials failed to demonstrate superiority over placebo. Even when statistical differences were found, no clinically meaningful differences were observed between treatment and placebo. Although Spravato is intended for depressed patients who are treatment-resistant and suicidal, the clinical studies excluded participants with any suicidal ideation/behavior in the past 6 months. Ironically, three study participants – all in active treatment – suicided during the trials.No long-term studies were performed. Given that Spravato was rushed through FDA approval and that it costs consumers between $3000 and $6000 a month for treatment, the public should be aware of the drug’s limitations and unknown risks of long-term use.” (Letter to editor by Ricardo Rieppi published on CSCSW listserv, 3/12/19)
Research on how ketamine works suggests it targets opioid receptors in the brain, so could its regular use lead to opiate dependence? Just what we don’t need, given that we’re in the midst of an opiate dependence crisis! And speaking of opiate dependence, there’s an interesting blog on the Mad In America (MIA) website on opiate addiction and its connection to depression.
Also this spring, a second new drug treatment was announced. This one is for post-partum depression, and is also super expensive ($34,000 for one intravenous dose). Here’s an article discussing the new drug (really a synthetic version of progesterone, a hormone produced naturally in the body) and how its cost and requirement of a 60-hr hospital stay will prevent most women from having access to it.
Finally, a study published in The Lancet, the British medical journal, by two UK psychiatrists received a lot of attention, because their research shows that withdrawal from standard antidepressant medications (SSRIs) is much more protracted and difficult than most doctors believe.
Many doctors have been taught to believe that SSRIs (selective serotonin reuptake inhibitors) are safe and non-habit forming, so they can be taken indefinitely, and also discontinued easily. This is only partially true. SSRIs do have fewer harmful side effects than the older generation of depression meds. They are not addictive in the same way that opiates or benzodiazepines are, meaning you won’t develop cravings. However, their effects and side effects are definitely not harmless, quitting them abruptly can have negative consequences, and many people have found that even a tapered withdrawal may cause unpleasant effects, which can last for many months, or even years in some cases.
Here’s the MIA take on this study: “How Long Does Antidepressant Withdrawal Last?”
And here’s an article published last year that described the struggles of many individuals to get off of SSRIs, which the new British study validates.
When Prozac, the original SSRI, first came out in the 1980’s, it was typically prescribed for six months to two years, and there were no reported problems with people discontinuing it. But the pharmaceutical companies promoted the idea that these medications could, or should, be taken indefinitely, for obvious reasons.
So what can we conclude from all of this? First, the mechanisms of how antidepressant medications work are still poorly understood. The theory that depression is caused by a chemical imbalance, specifically a lack of serotonin, has not been scientifically proven.
Second, depression is not like getting the flu or strep throat. There’s often no clearly identifiable cause, such as a virus or bacteria that can be tested for. There isn’t a predicatable course of illness. It shows up differently in different people, and even in the same person at different times. There’s even some debate whether it should be considered an illness, for these reasons.
And third, research on new treatments is usually funded or sponsored by pharmaceutical companies, who routinely sacrifice scientific rigor in their drive to push a new product to market, putting profits before people’s health and well-being.
There are many alternative treatments for depression, most of which are cheaper and have few or no side effects; several of them have been scientifically proven to be effective. These include dietary changes, behavioral changes around sleep and exercise, herbal remedies, nutritional supplements, self-help groups, social support networks, and various forms of psychotherapy, including cognitive-behavioral therapy, and my favorite, Mindfulness-based Cognitive Therapy. I often recommend that my depressed patients try a combination of these, and I’ve seen good results.
That’s the real news about depression treatment: if you start with improving sleep, exercise, and nutrition, then add social support, CBT, and mindfulness, it’s often possible to achieve better and longer-lasting recovery from depressive symptoms. So rather than keep chasing after that elusive “magic pill” (which I don’t believe exists) doesn’t it make more sense to try some of these alternatives?