When it comes to depression, options for medication are generally unreliable, and many individuals with more severe depression never find an antidepressant that works for them. Standard antidepressants are prescribed on more of a “trial-and-error” basis, so individuals must spend months or years trying medications to see if they work. Approximately 30% of people with depression don’t find relief from the first antidepressant they try, and the next one is only less likely to be effective. Each medication can come with a range of side effects that in some cases are more debilitating than the symptoms of depression. People struggling with depression are in desperate need of more consistent and reliable treatment options.There are now two exciting alternative options for people with treatment-resistant depression: TMS and ketamine.
Despite the immense limitations of traditional depression medications, these treatments are still relatively unknown and not considered main-line treatment. Both TMS and ketamine are available at some specialty mental health clinics such as TMS & Brain Health, who claim that success rates are higher when used with multiple modalities. They both have shown extremely promising results in both experimental and clinical data so far, and have the ability to give patients lasting relief. While standard antidepressants only work while they are present in the body, both ketamine and TMS have the power to alter brain function to improve depression well after treatment is over.
What is TMS?
TMS stands for transcranial magnetic stimulation. This technique has been used in the clinical field since the 1980s for measuring brain activity in experimental trials. It is completely non-invasive; the process involves using a small machine to send magnetic pulses through the scalp and into the cortex, which triggers neurons to fire. The magnetic pulses can be targeted to a specific area of the brain in order to stimulate neural activity in one area. When used to treat depression, a cortical area in the basal ganglia known to be related to depression is targeted.
TMS was first discovered as a treatment for depression in the 1990s, and it became FDA-approved as such in 2008. TMS is effective for over 60% of individuals — a significantly higher rate than any main-line antidepressant. Additionally, as many as 40% experience full remission from a TMS treatment course. A typical treatment course consists of 5 sessions per week for six weeks, totaling 30 TMS sessions. Once this is completed, patients can see relief for months or even years, and may schedule follow-up sessions as necessary.
As for health risks, TMS is also one of the safest treatment options available. Very few adverse health effects have been observed in clinical trials. The largest risk is the risk of seizure, which is less than .01%. For this reason, individuals with epilepsy or history of seizure may not be approved for TMS. Additionally, the treatment is not recommended for people with metal implants of any kind.
Of course, all medical treatments come with side effects. The most commonly reported side effects include headache or lightheadedness that subsides shortly after the treatment session. Patients typically describe feeling a knocking sensation or sensitivity on the scalp while the machine is on. Additionally, most patients find that these side effects diminish as the treatment course goes on.
What is ketamine?
You’ve probably heard of ketamine before; it has been used in the medical field since the 1970s as an anesthetic. In the early 2000s, researchers began testing it as a treatment for depression because of its unique interactions with the brain. The results were astounding — as many as 70% of patients with treatment-resistant depression had significant improvements, and about half responded almost immediately after the first dose. Ketamine’s impressive impact on depression is suspected to be related to its unique interaction with neurons.
Unlike other antidepressants that only temporarily alter neurotransmitter supply or activity within the brain, ketamine has the power to change neural pathways as soon as it is taken compared to TMS. When ketamine enters the bloodstream, it triggers glutamate production, which actually leads the brain to reform lost neural connections. This mechanism of action is attributed to ketamine’s immediate results and ability to catalyze lasting change in patients. Rather than mimicking regular activity in under-active areas of the mind, ketamine actually helps the patient stimulate, restore, and strengthen healthy neural circuitry and function.
There are a few different ways ketamine can be administered, with the two most common being intravenous infusions and a nasal spray. The esketamine nasal spray was FDA-approved under the brand name Spravato in 2019. The approval process was expedited due to the surprising experimental results, in order to make it more accessible to the public and individuals in need. As such, we can expect to see FDA approvals for the other forms of ketamine in the coming years.
The standard ketamine treatment course consists of six infusions or sessions over the course of 2-3 weeks. Just as with TMS, the course is followed by a long term of monitoring in which follow-up sessions can be scheduled. During treatment, patients may experience lightheadedness, mild hallucinations or floating sensations. Patients also commonly report feeling tired after the session. These side effects are mild, and patients are always monitored by a clinician the entire time.
As with any treatment for a mental condition, a mental health clinic should always create a personalized treatment plan tailored to the unique needs of the patient in order to deliver a comprehensive and supportive treatment.
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