How well do antidepressants work and what are the alternatives?
However, starting in the 1990s, researchers began to realize that depression much more complicated and that serotonin played only a nominal role. First, SSRIs increase serotonin levels immediately, but it takes several weeks before people start to feel better. And studies began to emerge showing that another brain system played a role: People with depression constantly smaller volume in an area called the hippocampus, which is important for mood regulation.
The the currently prevailing theory, Dr. Hellerstein said, is that chronic stress can cause a loss of connections — called synapses — between cells in the hippocampus and other parts of the brain, potentially leading to depression. Antidepressants are thought to work, at least in part, by helping the brain make new connections between cells. Researchers aren’t exactly sure how increasing serotonin with SSRIs causes these synapses to regrow. Medicines are one possibility increase levels of other brain chemicalscalled growth factors, which help create and expand these bonds.
Paper published earlier this year made headlines for presenting several decades’ worth of evidence that depressed people have less serotonin than non-depressed people. For most psychiatrists, the work revealed nothing new, and that did not mean that antidepressants were not effective (a widespread misinterpretation of the work). Instead, he found a fundamental disconnect between how the public views depression and how professionals think about it.
“To me, it’s an old theory for depression,” said Dr. Daniel Iosifescu, a professor of psychiatry at NYU Langone Health. “That was already overturned 20 years ago, so we’re just basically putting the nail in the coffin, so to speak.”
What alternatives to antidepressants are available?
Alternative treatments for depression have emerged that attempt to help the brain make new connections more efficiently—most notably ketamine and psychedelic therapy (not approved by the Food and Drug Administration). These interventions seem to be approx as effective as antidepressants, improving depression scores in roughly 60 percent of people who try them. More significant is that they are able to heal some of the people which do not fit to traditional medicines. However, the drugs are considered riskier and more invasive than antidepressants, so they are intended to be used as a last resort rather than a first-line treatment, Dr. Sanacora said.
Some psychiatrists have also begun recommending non-pharmaceutical treatments to help people with depression. dr. Hellerstein said that when evaluating a new patient, he now pays more attention to habits, such as sleep, diet and exercise, and would often recommend behavioral changes, therapy or meditation before medication. There is research to suggest that exercise can also help new connections grow in the brainand in some studies it has been shown that exercise does as effective as antidepressants in the treatment of depression. Meditation has been found to help with feelings of stress and anxietyand there is a clear connection between lack of sleep and anxiety in the brain.
“I think you’re giving a more complete assessment of the person’s lifestyle than you might have done in the late 1980s,” Dr. Hellerstein said.