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The New England Journal of MedicineDepression — Advanced Treatments for Treatment-Resistant Depression

Exploring Neuroplasticity and Advanced Therapies for Treatment-Resistant Depression

In the third episode of a four-part Double Take video miniseries on depression by the New England Journal of Medicine, Drs. Sanacora, Nikayin, and Cristancho dig into the evolving understanding of depression’s pathogenesis and discuss advanced therapies for treatment-resistant cases, including electroconvulsive therapy, transcranial magnetic stimulation, ketamine, esketamine, and psilocybin.

Key Points:

  • Challenges in Treatment: Primary care physicians often struggle with patients who do not respond to initial antidepressant treatments.
  • Advanced Treatments: Development of specialized treatments including electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), ketamine, esketamine, and psychedelics like psilocybin.
  • Systemic Barriers: Access to advanced treatments can be delayed due to systemic issues in mental health care and insurance constraints.
  • Evolving Understanding: Depression may be more related to brain connectivity and neuroplasticity rather than just chemical imbalances.
  • Individualized Approach: Treatment choices should be tailored to each patient’s severity, urgency, medical health, and affordability.
  • Equity in Mental Health: There is a need to improve the system to ensure broader access to advanced treatments.
  • Effectiveness of ECT: Despite misconceptions, modern ECT is a highly effective treatment with improved safety protocols.
  • TMS Development: TMS shows promise with ongoing research to optimize treatment protocols for better efficiency and effectiveness.
  • Ketamine’s Role: Ketamine and esketamine offer rapid antidepressant effects, with emerging evidence supporting their use.
  • Psychedelic Therapies: Psilocybin and other psychedelics are in early stages of research, showing potential but requiring cautious development.

“Despite being around for 80-90 years, modern electroconvulsive therapy (ECT) has evolved significantly, now using rapid induction of general anesthesia and muscle relaxants to minimize cognitive side effects and enhance safety.”

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