For many months now, people have been dealing with the pandemic, Which has brought both grief for the lives lost and anxiety about the threat of infection. At the same time, fires and floods have made it clear that climate change is not a fuzzy future concern, but an urgent issue. The economic impact of all these problems has also been challenging. It is little wonder then, that rates of anxiety and depression have been rising. What are the new approaches to managing depression?
The first step to managing depression is understanding what we are talking about. Grief is a normal response to loss, and anxiety is not an unusual response to stress. What distinguishes major depression from ordinary sadness? We discuss the symptoms, such as changes in sleep patterns or appetite, along with irritability, that could signal someone is suffering from depression.
Our guest, Dr. Andy Nierenberg, describes the difference between bipolar disorder and depression. He also points out that seasonal depression is not limited to winter. Some people have predictable symptoms of depression in the summer. They also tend to have trouble with jet lag, so they may be especially sensitive to changes in light exposure and timing. We also learn about the signals that a young person might be depressed. Whereas a few decades ago, psychiatrists were not sure that children suffered from depression, now scientists have evidence that they do. Consequently, doctors have developed ways to help with managing depression in youngsters.
Certain forms of therapy have excellent evidence to support their usefulness. Cognitive behavioral therapy, behavioral activation therapy and mindfulness-based cognitive therapy can all be very helpful. The challenge is finding a qualified therapist who has the appropriate training and experience.
Serotonin is a neurochemical that cells in the brain use to communicate with one another. Many of the most popular antidepressants such as fluoxetine (Prozac) or sertraline (Zoloft) work through serotonin. There are other medications for managing depression as well. For the most part, doctors try to pay attention to side effect profiles to find the drug that will be most helpful for a specific patient. The SSRI (selective serotonin re-uptake inhibitors) often have sexual side effects that can be quite distressing.
We don’t know exactly how the brain works nor how antidepressants affect it. The Dauten Family Center for Bipolar Treatment Innovation at Massachusetts General Hospital is systematically studying whether drugs approved for other uses can be repurposed for treating depression. Surprisingly, fenofibrate, an older medication that was once used to control blood lipids seems to be promising for people who have not responded well to conventional antidepressants.
Older medications such as monoamine oxidase inhibitors (MAOi) have fallen out of favor because patients need to pay close attention to diet and other medications. Nonetheless, they can be quite effective. Lithium has been used for bipolar disorder for years, and it is still one of the best treatments for this condition. Approaches that reduce stress, including meditation, forest bathing and exercise, can help boost the power of other treatments. In fact, there is evidence that exercise can affect one of the same pathways as fenofibrate. It also increases the output of brain-derived neurotrophic factor, BDNF, which also helps in managing depression.
Dr. Jerry Rosenbaum points out that some people who have not responded well to conventional antidepressants need more than one medication. That is because of the significant differences among individuals. It can be difficult, however, to predict which therapy will be most useful for a given patient. Device-based treatments such as TMS (transcrancial magnetic stimulation) or ECT (electroconvulsive therapy) are useful additions to the armamentarium. Rapid treatments such as esketamine (Spravato) and ketamine also hold promise for some patients. In addition, some psychiatrists are investigating the potential benefits of psychedelic drugs for managing depression.
Andrew Nierenberg, MD, is the Director of the Dauten Family Center for Bipolar Treatment Innovation at Massachusetts General Hospital. He is also Professor of Psychiatry at Harvard Medical School, where he holds the Thomas P. Hackett MD Endowed Chair. He is a leader in Clinical Studies of Depression & Bipolar Disorder. Dr. Nierenberg is Associate Director of the Depression Clinical and Research Program. He is also Director of the Training and Education program at the Massachusetts General Hospital Research Institute. Dr. Nierenberg's primary interests are depression, bipolar depression, and novel treatments for mood disorders. The photo is of Dr. Nierenberg. His website is https://dautenbipolarcenter.org/about/our-team
Jerrold F. Rosenbaum, MD, is psychiatrist-in-chief emeritus and director of the Center for Anxiety and Traumatic Stress Disorders and director of the Center for Neuroscience of Psychedelics at the Massachusetts General Hospital and Stanley Cobb Professor of Psychiatry at Harvard Medical School. His career has focused on mood and anxiety disorders, with a special emphasis on pharmacotherapy of those conditions.
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