Ketamine is a molecule that has been used for years for surgical anesthesia, also been abused as a street recreational drug that some researchers are looking into for a rapid treatment of severe depressive symptoms. It is still largely investigational, largely being administered in research studies and protocols, but there is some preliminary evidence that it may prove beneficial for people in a severe depression. It's thought not to produce a lasting effect, meaning that someone takes the medication and they remain depression-free for the rest of their life, but it is thought to perhaps jumpstart, if you will, that if someone is severely depressed, perhaps suicidal and they're administered this medication, that those feelings and thoughts could lift very rapidly, pull them out of that rut if you will, and then other sorts of treatments could then be administered and kick in to try to help maintain them to stay well. There are some potential risks associated with ketamine, which are also still being explored, including the significant concern for addiction as well as effects on blood pressure. Hopefully we'll know more about this as it continues to be studied.
Let's talk about some other medical but non-pharmacological forms of treatment - meaning things that your medical doctor or the psychiatrist might recommend, but that are not in the form of an actual pill that a person would take. One of the treatments that's medically offered for depression is called electroconvulsive therapy or for short known as ECT. ECT works by applying a small amount of electric current to the brain while a person is obviously under anesthesia in a controlled setting to induce a seizure, which is sort of an electrical overactivity of the brain. This is a treatment that has been around for a while and has been refined over the years in terms of its safety profile. From a data perspective, ECT does seem to help a lot of people who are struggling with severe depression, but from a practical perspective it is often reserved for the more severe cases of depression. People who have tried lots of other interventions (for example: therapy, a number of medications) and nothing seems to be helping them and they are in a very severe state (for example: suicidal or not eating and losing dangerous amounts of weight, having psychotic symptoms like they're hearing sounds or voices, losing touch with reality.) In those cases, it might be considered. Its use is restricted because A. it's not a practical form of treatment - it requires going under anesthesia several times a week for usually about four weeks or so. And B. there are some significant side effects that have to be considered. This is something to talk with your doctor about in terms of the full list.
Another form of medical treatment for severe depression is what's known as TMS or Transcranial Magnetic Stimulation. This is a newer form of treatment that is still being studied but is used quite frequently in the appropriate patient population. It works by generating magnetic pulses that are targeted at specific parts of the brain that are thought to help depressive symptoms. Unlike ECT, there is no seizure being induced and there is no need for general anesthesia, meaning that a person is not put to sleep during the procedure. It is usually performed more frequently than ECT. It could be even five days a week in an average course. The benefits relative to ECT are not fully established yet. Currently it is thought that it is not as beneficial as ECT is for severe depression, but it continues to be studied and developed. And this is something to ask your doctor about when you're considering various options.
Magnetic Seizure Therapy is an investigational medical non-pharmacological intervention for depression. On some level, it's a little bit of a blend between electroconvulsive therapy (ECT) and Transcranial Magnetic Stimulation (TMS) in that it uses magnets to induce a seizure that is thought to help depression. It is not widely available and it is still being researched, but it is hoped that this may also provide some relief in the future for the appropriate patients. Nitrous oxide is an anesthetic that's been around for years that is currently being explored at low doses to potentially help with the rapid treatment of depression. Repastinel is a medication that is being explored in research trials, hoping to work similar to ketamine; providing a rapid antidepressant response that may not be sustained that may be enough to pull a person out of a very severe depression in an acute situation.
Other times, people will treat their depression in what we refer to as a regular outpatient setting, where they will see their doctor or their mental health professional every week, every couple of weeks, depending on the severity of their symptoms as recommended by their doctor or a mental health professional. They'll continue going to work, they'll continue their regular routine, but will have check-in appointments at the specified frequency. Another level of treatment is what is referred to as a partial hospital program, commonly known as PHP or an intensive outpatient program, commonly known as IOP. These are very similar entities and therefore we'll group them together, which are basically day programs where a patient will be living at home, sleeping at home, but go a certain number of times a week for a good chunk (if not the entire day) to an intensive setting where they'll receive therapy, group therapy, medication management and other services. Again - meant to provide a more comprehensive package in the treatment of their depression.
Depression can be treated in a variety of different settings, depending on how severe the symptoms are. At the highest, most acute level is what we call inpatient hospitalization - meaning that a person goes to the hospital (it may be in voluntarily in some instances) to receive treatment. Sometimes people will voluntarily elect to go to the hospital as well, where they'll receive more intensive attention, medication therapy, hopefully psychotherapy as well that can help boost them and pull them out of the depression more rapidly. Inpatient hospitalization will be particularly appropriate in situations where there are concerns for safety. So for example, if a person is having thoughts of harming him or herself, it is very important to strongly consider inpatient hospitalization and sometimes this even needs to be pursued involuntarily to save a person's life. Below inpatient hospitalization is residential treatment. Residential treatment is where a patient will go and live in a particular place - a particular facility. It is not a locked facility, it is not a hospital, but it will often have a doctor or a mental health professional on staff to help with the treatment to convalesce. This may be appropriate for someone where there is not a significant concern for suicidality or other risks to health, but where the symptoms are still too severe to be managed while they're living at home.
There are many different mental health professionals who can adequately treat depression in different ways: a psychiatrist is a medical doctor who can prescribe medications and other forms of treatment for depression and can also provide psychotherapy (which is a fancy term for talk therapy) that uses dialogue to improve the symptoms of depression. Other professionals included psychologists, social workers, marriage and family therapists, who are all specialists in providing psychotherapy and can be extremely helpful in treating the depression. So if you're looking specifically for medication, a psychiatrist would be the way to go. If you're looking for therapy, any one of those professionals would be a fine way to go.
There are a number of red flag symptoms that should encourage someone to seek help for depression right away. These would include things like: thoughts of harming oneself or others, or if the depression is tangibly affecting them in a very direct way. So for example, if someone is in danger of losing their job, losing a relationship due to their depression, they should certainly seek treatment right away. The other general recommendation we give when it comes to seeking treatment is if the depression is not going away. What's considered not going away? Obviously there are different opinions on how to define that. A general rule of thumb we give people is about two weeks. If a person is having consistent symptoms for one week, that could be a fluke. Once it's getting to two weeks, that's already getting closer to the point where it's probably a good idea to speak to someone just to try to turn the current before it becomes more entrenched.
Insurance coverage and the treatment of depression is somewhat variable. Some psychiatrists take insurance, some do not. Some therapists take insurance, some do not. If you're having a hard time finding a doctor who takes your insurance and it's important for you to use your insurance, a good first step is to call the insurance and ask for a list of the providers who are in network for them (meaning the ones who are covered to the greatest extent) and you can then either ask other people you know if they recognize any of the names or try calling some of the doctors and see if they seem like a good fit. Hospital services will usually be covered by most insurances. Partial hospital programs will usually be covered by most insurances, residential programs - it may vary more. So obviously for each of these issues, it's important to talk with your insurance ahead of time in order to ensure that it is indeed covered.