Charles Surette, MD
No two cases of depression are equal; every patient is unique, has their own needs or treatment preferences, and may respond to treatment differently. Many times, patients will feel better after receiving a course of talk-based therapy (also known as psychotherapy). Other times, patients may feel better after receiving treatment with a single medication known as an antidepressant. Still other patients may benefit from a combination of medication and talk therapy
In rarer cases, patients may receive medication, therapy, or a combination of both, and still report distressing symptoms of depression such as feeling sad or blue, not eating or sleeping well, or a having a loss of interest in activities that they typically enjoy. In these situations, a patient and their mental health provider may pursue what is known as an adjunct treatment for their depression.
What does “adjunct” mean? When talking about treatment for depression, “adjunct” refers to medications or other treatments that, although they are not the first choice of treatment for depression, may be added to a patient’s treatment (such as an antidepressant) to help them to feel better when initial treatments have not. Some examples include:
Mood stabilizers are a class of medication that work in a variety of ways to treat, and in some cases prevent, extreme highs and extreme lows in mood. Examples include lithium, valproic acid (also known as Depakote), and carbamazepine (also known as Tegretol). These medications can help to regulate electrical and chemical signals between cells in the brain, known as neurons, in order to help to treat depression, and can often be used safely alongside an antidepressant when treatment with an antidepressant has not sufficiently treated symptoms of depression.
Antipsychotics are primarily used to treat psychosis, a condition in which a person has difficulty distinguishing what is reality and what is not. However, antipsychotics can also be used in conjunction with antidepressants to treat depression. Many antidepressants affect the regulation of certain chemicals in the brain, known as neurotransmitters, to treat depression, such as serotonin or norepinephrine (also known as noradrenaline). Antipsychotics frequently target another neurotransmitter known as dopamine, which, in addition to its role in psychosis, may also play in a role in causing or worsening symptoms of depression, such as lack of motivation, problems with thinking (also known as cognition), and other symptoms. Your provider may recommend adding an antipsychotic medication to your antidepressant in order to target multiple neurotransmitters at the same time to treat your symptoms, as well as to boost the effect of your antidepressant, as some antipsychotics may help to increase levels of certain antidepressants in the body.
Ketamine has long been used as a part of anesthesia for surgical procedures, but is now being utilized in treatment of depression at lower doses than what is used for anesthesia. While the mechanism of action of mechanism is still being studied, it is believed to target different chemical receptors in the brain that may lead to the formation of new and different connections between neurons to treat depression.
Ketamine can be administered via two different methods: via an injection into a vein (also as the intravenous method) or via a spray into the nostrils (also known as the intranasal method). Intravenous (IV) ketamine therapy is usually conducted twice per week for the first 4-6 weeks of treatment; this is known as the acute or induction phase of treatment, during which your provider may adjust your ketamine dose based on how you’re feeling, including symptoms of depression or if you experience any side effects. You and your provider may then discuss a plan for the maintenance phase of treatment, which involves receiving a steady dose of ketamine at less frequent intervals.
Similarly, the intranasal method (which uses a version of ketamine known as esketamine, or by its brand name, Spravato) features an acute phase followed by a maintenance phase of treatment. Similar to the intravenous method, the intranasal method is usually administered twice per week for the first 4-6 weeks, with you administering the medication yourself under the close supervision and monitoring of your provider. Following the acute phase, you and your provider may discuss a maintenance treatment schedule and dose based on your symptoms.
Whether you and your provider choose the intravenous or intranasal method of administering ketamine/esketamine, both methods of treatment may be done in the office without the need for admission to the hospital, although you will need to be monitored in the office for a period of time both during and after each treatment session.
Transcranial magnetic stimulation, or TMS, is a treatment for depression that does not use any medications. TMS utilizes magnetic currents from a device placed next to the head to induce and alter electric signals in parts of the brain that are believed to be related to depression. In addition to not requiring any additional medications, this treatment is non-invasive and does not require any surgery or implants. Treatment typically lasts for 4-6 weeks, and you can often continue your current oral antidepressant treatment at the same time while undergoing treatment with TMS.
Together, one or more of these treatments added to an antidepressant, sometimes in conjunction with talk-based therapy, can help to improve symptoms of depression that have not improved with an antidepressant or talk therapy alone. At Principium Psychiatry, your provider will work with you to discuss your current symptoms, your current goals and preferences for treatment, and collaborate with you to decide which adjunct treatment, if any, may be right for you. Call 212-335-0236 today to talk to a member of our team and to schedule an appointment with one of our providers. Principium Psychiatry has offices at Grand Central/Midtown Manhattan, Wall Street/downtown Manhattan, Greenwich CT, and Santa Monica in Los Angeles.
