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Depression Best Practices

Many patients cannot tolerate or do not respond to medications for depression and may need assistance creating a “treatment window.” That is, getting to a place where they can focus long enough and have enough energy to actively participate in treatment.  What are the options?  Learn about new treatments including Ketamine, transcranial magnetic stimulation and CBD—the non-hallucinogenic component of hemp.


Ketamine and Rapid-Acting Antidepressants: A Window into a New Neurobiology for Mood Disorder Therapeutics
Major depressive disorder (MDD) is a leading cause of disability throughout the world. In the United States, the estimated lifetime prevalence is ~17%. More than 20 different antidepressant medications, all of which target monoaminergic systems, are currently available. However, the efficacy of these medications is limited, with a substantial proportion of patients failing to achieve a sustained remission.


Ketamine for Depression, 1: Clinical Summary of Issues Related to Efficacy, Adverse Effects, and Mechanism of Action
Ketamine has relatively recently come to the attention of doctors as an effective tool to create that “treatment window” which may help patients who are severely depressed achieve temporary relief while other medications, like SSRIs and SNRIs and talk therapy take effect.  Benefits of a single dose of ketamine appear to wear off within 1 week. Ketamine may produce transient dissociative symptoms, cognitive impairment, and even psychotomimetic symptoms in healthy volunteers.   Maintenance treatment strategies with intranasal, subcutaneous, intramuscular, and iv ketamine indicate that the antidepressant benefits of ketamine can be maintained by repeated dosing at 2- to 7-day intervals for months.

One could hypothesize that risks of ketamine abuse are significant since this veterinary tranquilizer produces such dramatic effects so quickly.  However, some argue it may be worth the risks in acutely suicidal patients.  The VA is currently using it as a treatment for PTSD and Treatment Resistant Depression with high suicide risk.

Selective Pharmacological Augmentation of Hippocampal Activity Produces a Sustained Antidepressant-Like Response without Abuse-Related or Psychotomimetic Effects
Researchers have found a drug that has similar antidepressant effects to ketamine without the addictive effects called L-655,708.


Repetitive Transcranial Magnetic Stimulation (rTMS)
Updated Review on the Clinical Use of Repetitive Transcranial Magnetic Stimulation in Psychiatric Disorders
For patients with depression with psychotic features, ECT  showed better response and remission rates than HF rTMS.  In depression without psychosis, HF rTMS was as effective as ECT.  It appears that the effect from rTMS is not maintained after treatment stops.  Induction of a seizure is the most important safety concern of rTMS treatment. Theta Burst Stimulation or “TBS” seems to have the highest risk of triggering a seizure, followed by the treatment with the Brainsway coil at 6/5000.

Safety of Transcranial Magnetic Stimulation in Children: A Systematic Review of the Literature
It appears children have adverse events related to rTMS at about the same rate as adults, but there are no long-term studies regarding the effect rTMS may have on the adolescent brain which is still developing.  Corey H Allen, BS,1 Benzi M Kluger, MD, MS,2 and Isabelle Buard, PhD


CBD for depression
Translational Investigation of the Therapeutic Potential of Cannabidiol (CBD): Toward a New Age
Clinical use of CBD, a compound that does not produce the typical subjective effects of marijuana induced by Δ9-THC, has clearly shown anxiolytic, antiepileptic, and antipsychotic properties, among other effects.  CBD will interact with antidepressants and antidepressant supplements such as 5-HTP, SAM-e and St. Johns Wort they should not be taken together without close supervision from a physician.  Additionally, CBD is not regulated for potency since it is not a “medication” so dose and effectiveness may vary across manufacturers.  There is currently no established recommended dose for CBD to treat depression. Click here for a video on CBD and Mental Health.

Emerging evidence for the antidepressant effect of cannabidiol and the underlying molecular mechanisms.
Recent evidence suggests that CBD promotes both a rapid and a sustained antidepressant effect in animal models. CBD has a complex pharmacology, with the ability to interact with multiple neurotransmitter systems involved in depression, including the serotonergic, glutamatergic, and endocannabinoid systems.

Linking antidepressant performance with pain network connectivity
Several regions in the pain network have been associated with depression, in particular the cingulate and insular cortices. Additionally, chronic physical pain can lead to depression and depression can increase sensitivity to pain.Two SNRIs (selective norepinephrine reuptake inhibitors) duloxetine (Cymbalta) and desvenlafaxine (Pristiq) have been associated with reduced connectivity in a thalamo-cortico-periaqueductal network that has been associated with pain.  This indicates that for a subset of patients with depression and concurrent pain, SNRIs may be preferable to SSRIs or other medications for interventions.


Common Conditions that Mimic Depression
Many patients who do not respond fully to antidepressants and/or talk therapy may likely have other underlying issues caused by hormone imbalances, nutritional deficiencies or sleep/circadian rhythm disruption.  Below you will find the most commonly missed concurrent diagnoses.

  • Hypothyroid
  • Polycystic Ovarian Syndrome
  • Low Testosterone
  • Estrogen Dominance
  • Premenstrual Dysphoric Disorder
  • Seasonal Affective Disorder / Circadian Rhythm Disorder
  • Iron-Deficiency Anemia
  • Vitamin D Deficiency
  • Lyme Disease
  • Sleep Apnea


CEU Courses Related to Depression


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