Depression affects around one in five Americans. And while most people respond to antidepressant medications, for the one third of those who don’t get better, the treatment options are pretty stark.
In this week’s Exploradio, WKSU’s Jeff St.Clair looks at a new study that compares two therapies, both of which have their share of problems.
Deena Nyer Mendlowitz says at one point, thoughts of suicide had become so normal that planning her last day seemed pretty routine.
“I took a lunch break in the middle," she says, "that’s how routine it felt to me.”
“I went into the hospital and into an outpatient program and I was not getting better ... they suggested shock therapy.”
It's otherwise known as Electroconvulsive Therapy or ECT. And it's still the most effective recourse for what’s called treatment resistant depression – a condition that affects nearly 15 million Americans.
Mendlowitz has had more than 60 ECT treatments. She says it was a life-saver.
“I got better. It was amazing," she says, "I felt like the heaviest weight had lifted off of me, like when you go to the dentist and you get X-rays and they put that lead vest on you; it was like somebody took off that lead vest, and it felt great.”
But there have been drawbacks. Her memorization skills were shot.
“I’d be on stage and I couldn’t focus on what was happening in the improv scene before," says Mendlowitz, "I'd be like, 'What just happened?'"
Mendlowitz still finds random holes in the fabric of her memories. “I can’t remember my son’s birthday," she says, "but I can still remember every episode of Beverly Hills 90210.”
ECT vs Ketamine
Memory loss is only part of ECT’s PR problem. It’s had a troubled past and some unflattering media portrayals – think of the scene from "One Flew Over the Cuckoo’s Nest."
It's an unwarranted stigma, says one of ECT’s biggest backers, Charles Kellner of Mt. Sinai Hospital in New York . He's treated patients with ECT for more than 30 years.
"ECT is clearly, hands down, the best treatment for those patients with very serious mood disorders.”
Kellner is now part of a Cleveland-based study that may put him out of business, but he’s not worried. "The idea," he says, "is to compare the new kid on the block with the tried-and-true treatment that’s been around for a very long time.”
The new kid on the block is the drug ketamine.
Very Special K
Cleveland Clinic researcher Amit Anand is leading the comparison study, and he was part of the team at Yale that discovered that ketamine could be an effective treatment for severe depression.
“That was totally unexpected,” says Anand.
But Anand says some doctors are now offering ketamine as an experimental treatment for depression at designer-drug prices.
“Some places are charging as much as $1,000 per infusion," says Anand, "and the person has to get six to nine infusions for the antidepressant treatment.”
It’s not covered by insurance.
That’s a situation his study might change with help from an $11.8 million grant from the Patient Centered Outcomes Research Institute, or PCORI, a little known outgrowth of the Affordable Care Act that gives doctors and patients concrete evidence on the best treatments for diseases.
The grant puts ketamine up against the well-established ECT to see which works best for treatment resistant depression.
Yale researcher John Krystal first discovered that, in small doses, ketamine can immediately lift the weight of severe depression.
“And from the very first subject we had the sense that we were onto something quite surprising and perhaps extremely important.”
Important, says Krystal, because ketamine has opened a new understanding of the root causes of depression and its treatment.
“Ketamine itself may be the initial or prototype drug for a whole class of new antidepressant medications that might be developed over the next decade or two."
Krystal’s convinced that ketamine, rather than shock therapy, should be on the front line of treatments for people most at risk of suicide.
“If all things were equal," says Krystal, "then ketamine should probably be administered before ECT just because the risk seems a little bit less.”
Ketamine can make people pretty woozy, it has a sordid history as an illegal narcotic, and it is equal to ECT in that requires a few hours in a clinic and can have disturbing side effects.
That’s why Patient Centered Outcomes Research Institute Executive Director Joe Selby says this is just the kind of comparison that his agency was designed to fund.
“You don’t just need to know which one treats your depression better; you need to know what are the side effects across a range of different outcomes,” says Selby.
The study led by the Cleveland Clinic will involve 400 severely depressed people; half will receive ECT, half ketamine.
The results, he says, could help patients choose which is the safer, more tolerable, and more effective treatment for a devastating illness.