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MENTAL HEALTH
CHALLENGES

A majority of patients will improve, especially if given environ- to be useful for treatment in animal models of depressive illness.
mental, psychotherapy and medication treatments. They will require A few physicians started using ketamine in the 1960s, primarily
appropriate psychiatric referral if they do not respond, or immedi- for anesthesia. In the 1990s ketamine was being abused for it’s
ately if they are suicidal, or psychotic. For thoroughness, brief men- psychedelic properties and called “Special K.” Recent studies have
tion is given below to additional types of treatment available for found it a very useful treatment for depression, with a faster onset
those patients not responding to traditional psychiatric augmenta- of action, including the decrease of suicidal ideation, than tradi-
tion, psychiatric polypharmacy and dosing increases. tional antidepressants.

* Neuromodulation Treatments Ketamine is administered IV, in outpatient settings, by anesthesi-
If medication adjustment and augmenting strategies by a psychi- ologists with close medical monitoring. The best dosing regimen
atrist are not helpful, there are two types of “electrical” treatments is still being determined, and is expensive to use, because of the
given by psychiatrists, and a third which some patients pursue. close monitoring required. However, just released in March 2019
is a nasal version of ketamine, Spravato, (intranasal eskeketamine,)
* Electroconvulsive therapy (ECT) is still considered the “gold stan- which is not yet available to psychiatrists. It usually needs to be
dard” for treatment resistant patients, although there is still some given three to four times over a eight week period, and the length
stigma attached to this treatment. This may be given as an outpa- of response for the average patient is still being determined. It is
tient, with 4-12 treatments initially over 3-5 weeks, and then ta- an exciting pharmacological advance. Both ketamine infusions and
pering off frequency when improvement occurs. It is very safe, the intranasal Spravato approach will likely coexist for some time,
quite effective, but often has temporary memory impairment. The until the exact pros/cons of each approach are better clarified.
patient may not drive following a treatment session, and some
psychiatrists prohibit driving for the entire course of treatment, SUMMARY
as there is temporary impairment of memory and judgment. The new onset of depression in late life is less common than in
younger individuals, but the total prevalence is quite high, from 14-
* Transcranial magnetic stimulation (TMS) is a newer electrical treat- 40%. Numerous risk factors are known, which would raise one’s sus-
ment, which is painless, does not require general anesthesia and picion about the need for more in-depth assessment. Although
does not produce a generalized seizure. Treatment is given 5 days elderly patients may have many somatic symptoms, the same criteria
a week for 3-6 weeks, and the patients can usually drive themselves are used for diagnosis as in younger patients. It is important to screen
to/from treatment. Often in medication treatment failure, ECT for suicidal ideation and intent, and to take appropriate steps. Various
or TMS are covered by insurance. laboratory studies can rule-out medical causes, although the formal
* Transcranial direct current stimulation (TDCS) is a third type of diagnosis of depressive illness is still clinical. Treatment of geriatric
neuromodulation treatment. This is not a physician prescribed or depression is usually done in a primary care setting. The medical
directed treatment, but one about which physicians should be treatment of depressive illness is similar to that of younger patients,
aware, as patients may inquire about it. Individuals purchase the although environmental and psychological treatments are also often
instruments for $160-$600, and they are used at home. A common indicated. If improvement does not occur, specialty referral and
treatment protocol would be 20-30 minutes/day, for 2-6 weeks. complex medical or neuromodulation methods (ECT, TMS) are
Comparison studies to ECT and TMS are lacking, and TDCS often useful. Successful treatment results in a better quality of life,
would not be used for treatment resistant depression. Some pa- less morbidity from medical problems, and prolongation of inde-
tients report they are quite useful for mild-moderate depression, pendent living. Accurate diagnosis and treatment is beneficial to the
but are rarely physician recommended. patient, appreciated by the family and gratifying to the physician.

* Newest treatments. The first “really new” approach in 60 years is
that of ketamine. The MAOIs, tricyclics, and SSRIs and “mixed Dr. Frederick Brown is a psychiatrist in general outpatient practice with an
action” antidepressants all putatively affect the production, release, interest in comprehensive treatment of adult and geriatric patients. He is well
or reuptake of dopamine, norepinephrine, and/or serotonin. In versed in medication treatment, and various types of psychotherapy, He believes
reality, alteration of brain neuroplasticity is the more likely mech- psychotherapy is often useful, and prefers to combine psychotherapy with med-
anism. In the early 1990s, NMDA receptor agonists were found ication in the treatment of most patients.

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