Top Treatment Modalities for Depression

The psychiatrist's armamentarium to treat depression holds promise with a growing arsenal of integrative and pharmacologic options.

An extensive body of evidence has demonstrated antidepressants are effective, but other modalities are available, as discussed in this slideshow.

For reasons we do not understand, everyone requires a different amount of sleep. The general range is between 6 and 9 hours/night. A good night's sleep is foundational to maximal functioning, lowered stress, good reaction time, and enhanced cognitive function. Strategies discussed here.

As a generalization, a “heart-healthy” diet is also a “brain-healthy” diet. Moderate- to high-intensity aerobic and strength exercise training slow cognitive decline over the long term and has benefits for mental well-being. According to H. Steven Moffic, MD, beyond symptom improvement, spiritual and social support address the meaning of the patient’s life and how they relate to meaningful values of loved ones as well as the surrounding community. This can be applied to 15-minute medication checks by asking patients what gives their lives meaning then trying to see how medication can play a role in that.

Light therapy has been an area of interest for researchers. In a controlled setting, light exposure with a 10,000-lux fluorescent light box for 30 minutes first thing in the morning has been found beneficial in some patients. Patients should not use a sunlamp, tanning lamp, or halogen bulbs, and looking directly at the light can cause damage to the eyes. Mindful and relaxation practices are also instrumental in contributing to quality of life. Meditation is a process and practice available to all, as discussed in The Tool Within.

Of the many choices psychiatrists have, selecting the first-line antidepressant is largely a decision reached after weighing the risks and benefits of each drug with each patient’s presenting symptoms, functional impairment, lethality, past treatment history, preferences, comorbid psychiatric and medical conditions, motivation, and willingness to participate in other effective treatments such as cognitive behavioral or interpersonal psychotherapy.

There are approximately 30 FDA approved medications that have shown effectiveness in treating a major depressive episode of unipolar depression. These antidepressants should NOT be used to treat depression in patients with bipolar I disorder, as they can destabilize their mood and may “flip” a patient into hypomania or mania.

FDA-approved medications include olanzapine/fluoxetine combination; aripiprazole, quetiapine XR and brexpiprazole; and intranasal esketamine.

L-methylfolate 15 mg/day serves as a methyl group donor that may help in the brain’s synthesis of the monoamines dopamine, norepinephrine and serotonin. S-adenosylmethionine (SAMe) studies have used between 800 mg and 1,600 mg/day, but these are not as well studied as L-methylfolate.

The big one here is St John’s Wort (Hypericum perforatum) – usually dosed at 300 mg 3X/day. However, it is not FDA approved, and its purity can vary dramatically from brand to brand, and also within the same bottle. An important caution is that St John’s Wort induces a very important liver enzyme that breaks down many prescription drugs = CYP4503A4; this can have major clinical consequences such as hypermetabolizing oral contraceptives resulting in ovulation and pregnancy.

The underlying substance use disorder should be treated to exclude it as the cause of a person’s depression. Some substances (eg, alcohol, opioids, central nervous system depressants) can cause depression, and others (eg, cocaine, methamphetamine) cause depression during withdrawal.

The list here is quite long. A sampling includes obstructive sleep apnea, hypothyroidism, anemia, chronic viral infection, and pancreatic cancer.

Biological treatments for mood disorders have largely focused on altering monoaminergic neurotransmission, with only partial success. "In the landmark STAR*D trial, 1 out of 3 patients did not achieve remission with a 4-tiered monoaminergic treatment algorithm.. . . Neuromodulation therapies take an alternate approach: directly altering the brain’s electrical activity through electro-magnetic stimulation." See: Neuromodulation Approaches to Mood Disorders