Effective, FDA-approved treatments for depression continue to expand on pace with the increasing need for care. In addition to behavioral therapies, medications and various forms of gentle magnetic stimulation to the brain, a great deal of research is now also being done on hallucinogens for resistant depression.
According to the Census Bureau’s Household Pulse Survey, approximately 50% of adults ages 18-24 reported symptoms of depression and anxiety in 2023, compared with about a third of adults overall. These worsening statistics are the result of social isolation and life disruption owing to the pandemic.
Symptoms of depression can include feelings of sadness, or hopelessness and a loss of interest in normal activities, such as relationships, sex, work or sports. Many will self-isolate, while others have angry outbursts or frustration. Sleep disturbances are common. Lack of energy, poor concentration and difficulty making decisions are common. Feelings of self-blame might arise as well as loss of appetite and weight loss or increased cravings for comfort food and weight gain. Depression can cause unexplained physical problems, such as back pain or headaches. It might result from genetic tendencies or may be associated with underlying health conditions such as traumatic brain injury, post-traumatic stress disorder, chronic pain, sleep apnea, stroke, heart attack and cancer.
Psychotherapy provided by a psychiatrist or psychologist is highly effective either as a single intervention or in combination with medication. Cognitive behavioral therapy, for example, is a time-limited, practical treatment that aids in the management and resolution of depression. Beginning with the COVID-19 pandemic and continuing as appropriate, access to online clinical encounters has improved. The Department of Psychology at Manakai splits providers’ time between face-to-face and online visits. We continue to bring on more therapists to keep pace with the robust demand.
The first major medical breakthrough for the treatment of depression was a family of medications known as tricyclic anti-depressants, released to the market in 1959. They work well but have the side effect of sleepiness and now are more often used to treat insomnia. In 1987 the FDA approved another group of drugs, SSRIs, that increase serotonin levels in the brain. Fluoxetine (Prozac), the first SSRI in the U.S., markedly reduced hospitalizations for depression. In 1993 the FDA approved venlafaxine (Effexor), the first of one more class of drugs that support not only serotonin, but also norepinephrine. Serotonin support alone leaves many patients feeling better but lacking motivation. This often improves once norepinephrine balance in the brain is restored.
Nonetheless, certain patients have been through at least two trials of psychiatric medication for depression and have also completed a trial of psychotherapy yet fail to find relief. Today there are emerging options for treatment of resistant depression. These include newer methods for transcranial magnetic therapy and a drug called ketamine. Additional hallucinogenic drugs such as psilocybin are currently subject to intensive, quality research. Psilocybin is now legal for selected use in Colorado and two counties in Oregon.
Ketamine is FDA-approved for depression and may be used in Hawaii, if administered by a psychiatrist or psychiatric nurse practitioner. Traditionally, ketamine has been employed as a general anesthetic, but in lower doses research has shown benefits for depression and addiction.
Transcranial magnetic stimulation, or TMS, is a drug-free, painless, noninvasive option for treatment of depression that has a good safety profile and is easily administered in a medical office. TMS involves carefully placing a hand-held device on the head to give pulsed magnetic treatment while patients are fully conscious. It is FDA-approved for the treatment of resistant depression and is covered by most health insurance carriers, including HMSA, Medicare, Veterans Administration and Tricare. The FDA has also approved TMS for obsessive compulsive disorder and smoking cessation, but these diagnoses are not typically covered by insurance. At Manakai we have treated patients with traditional TMS as well as MeRT, a new proprietary method that offers more targeted treatment. Because it is more specific, the amount of magnetic stimulation for a therapeutic effect is typically less than traditional TMS. MeRT has also been found to be useful for traumatic brain injury, post-traumatic stress disorder and autism.
The treatment of depression is well suited to a multidisciplinary, team-based clinical environment. Our MeRT-informed TMS treatments are done in close coordination with our behavioral health specialists, neurology and, as appropriate, our primary care providers. When indicated, our patients with depression might also receive a study in our sleep lab. Acupuncture and culinary medicine may be included in the treatment program.
To conclude, depression is among the leading causes of disability in the U.S. FDA-approved treatments for depression continue to expand as the number of people suffering from depression steadily rises. Clinical outcomes benefit from treatment in a collaborative medical setting.
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Ira “Kawika” Zunin is a practicing physician and medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center: manakaiomalama.com. Submit questions: info@manakaiomalama.com. His column appears the first Wednesday of each month.
