Why Ketamine Treatment for Depression Isn’t Enough

5 Essential Rules for Holistic Approach to Treatment-Resistant Depression

An active man biking outdoors for a holistic approach to treatment-resistant depression instead of using ketamine or TMS.Depression is indeed a disease. And as the name of our Minneapolis psychiatry clinic suggests, it’s a disease of the brain AND body. While depression is completely treatable in the vast majority of cases, severe depression or treatment-resistant depression can be complex to treat and even intractable if not addressed holistically. 

By holistic, we don’t mean ‘all natural.’ To the team at Advanced Brain + Body Clinic Ketamine TMS, holistic mental health treatment means treating the whole mind and body because the outcome is stronger and longer lasting, while helping depression patients live better and avoid relapses.

Don’t get me wrong. We prescribe ketamine and Esketamine/Spravato because they are powerful psychiatric tools, and increasingly covered by insurance, along with transcranial magnetic stimulation or TMS. But they are considerably more effective when the brain plus the body work together for enduring mental health. 

We prescribe ketamine and Esketamine/Spravato because they are powerful psychiatric tools . . . But they are considerably more effective when the brain plus the body work together for enduring mental health.

Here are 5 essential rules for treating depression in general and treatment-resistant depression in particular. While it’s easy to find a ketamine infusion clinic out there, make sure you are working with a mental health doctor or psychiatrist with the experience of treating all levels of depression, anxiety and PTSD. 

1. Improve lifestyle issues

    • Exercise. Exercise increases Brain Derived Neurotrophic Factor (BDNF), possibly the greatest enhancer of neuroplasticity (an adaptable brain) the body makes.  If you have not been an exerciser, it is difficult to start exercising. It is crucial to develop a support system that can help you get started. 
    • We use our TMS technicians as part of that support system. Life coaches or psychotherapists are another option. Lifestyle changes should be considered an integral part of psychotherapy if the goal is improved mood. Start slow and increase slowly. Do something you enjoy. Try to exercise outside, so you can take in sunlight and nature. Aim to exercise at least 30 minutes, 6 days per week. Set goals for how much and how long you aim to exercise. And forgive yourself if you miss a day occasionally.
    • Eat better. 
      • Stop or greatly reduce the consumption of processed food. 
      • Eat predominantly vegetables. Try to eat a salad for at least one meal each day. If you eat meat, try to eat grass-fed meat or wild-caught fish. 
      • Stop or greatly reduce consumption of sugar. If you do eat sugar, consider it a rare treat. 
      • Greatly reduce consumption of bread. Many people have subtle gluten sensitivity. Many breads are sources of empty calories. 
      • Strongly consider intermittent fasting. Fasting causes ketosis, which is another factor that increases BDNF. Do not eat after dinner and until as close to noon as possible. Try to fast 14 to 16 hours per day. 
      • Meditate. There is evidence that meditation increases neuroplasticity. On a purely psychological level it allows you to let problems go for a time, usually resulting in a better perspective on problems once you stop meditating. 
    • Socialize. Socialization increases the release of oxytocin. Oxytocin not only helps you feel connected to your friends, but also has an antidepressant effect. Most people become isolated when they are depressed. The human animal needs social connectivity. The pandemic has created a major headwind working against social connectivity. It may be good to intentionally reach out to old friends and reconnect.
    • Sleep. Sleep is crucial to brain health. During sleep your brain empties waste products made during the day by your brain. Perivascular channels, the glymphatic system, only open up during sleep and are crucial to cleanse your brain. Insomnia is a common problem when people are depressed. The best way to improve sleep is to exercise, eat well, meditate regularly and socialize. Night shift work is bad for your brain. If you are depressed and working night shifts, even part of the time, consider changing to a job that allows night sleep. Medications for sleep are a last resort.

2. Get a full biological (lab) and/or genetic assessment from an advanced psychiatry clinic for problems that may be preventing improvement including hormonal problems, vitamin deficiencies, mineral level abnormalities, metabolic problems, and inflammation. Basic thyroid testing, a complete blood count, and a metabolic panel are not enough. Be sure your doctor has looked deeper than those few tests. Further, genetic testing can help determine which antidepressants may be most helpful and can identify genetic variants that may respond best to the use of certain supplements. 

We have treated hundreds of people with Treatment Resistant Depression at Manlove Brain + Body Health. We have done extensive lab evaluations on most of those people. Most of our patients have at least 5 significant lab abnormalities which can be improved by lifestyle changes, supplements, or pharmaceuticals. 

3. Consider alternatives to antidepressants. If you have tried four or more antidepressants, there are other readily available and effective depression treatments such as TMS therapy, ketamine, or ECT. There is a well-known study, the STAR D study, which showed that if you have failed four or more antidepressants you have only a 1 in 10 chance of responding to another antidepressant. This is when alternatives to SSRIs are critical for unipolar depression.

This is, in part, because most of the common antidepressant medications have similar mechanisms of action: they elevate monoamines including Serotonin, dopamine and norepinephrine. However, if you have major depressive disorder, having the strongest antidepressant such as brain stimulation, may be needed to get you out of your depressive episode.

The same group of people that has a 10% chance of responding to another antidepressant has a 70% chance of responding to TMS or ketamine.

If you have not responded to typical antidepressants, your doctor should treat your depression in a different way.  Both TMS and ketamine are very safe.  Though TMS and ketamine are great strategies for treating depression, remember that you can greatly reduce your risk of relapse by following the lifestyle strategies noted in #1, above. 

4. Abandon the notion that there is “one thing” that will resolve your depression. Treatment resistant depression is usually multifactorial. We have had many patients with treatment resistant depression come to our psychiatric clinic seeking the one thing that will help their depression. Sometimes they request genetic testing so they can find the drug that helps, sometimes they come pursuing TMS or ketamine. 

Most patients require more than one intervention to resolve their depression. We can often treat depression temporarily with the help of an antidepressant, TMS, ketamine, or ECT, but if we can develop a plan to address the other factors that contribute to depression, people sustain remission much longer.  This holistic approach to depression will also help you see results faster.

5. Consider adding psychotherapy as an adjunctive process. Many of us have stressors in our lives that are difficult to navigate or have emotional triggers that cause endogenous depression and anxiety. If these problems are addressed simultaneously, there is a better chance of successful treatment and less risk of relapse.  

Co-morbid diagnoses, such as post-traumatic stress disorder (PTSD), are frequently unrecognized and untreated.  This lack of attention to other underlying problems can prevent symptoms of depression from improving.  It is therefore critical to utilize evidenced based trauma therapies when appropriate, including Cognitive Processing Therapy (CPT), Prolonged Exposure (PE), Eye Movement Desensitization Therapy (EMDR), Accelerated Resolution Therapy (ART), or Cognitive Behavioral Therapy (CBT).  

Other diagnoses that are frequently overlooked may include Attention Deficit/Hyperactivity Disorders (ADHD) in 5% of people, and personality disorders, which involve unhealthy patterns of thinking, feeling and behaving, in over 10% of people.

While that may seem like a lot of information, the most important takeaway is: holistic treatment for depression is the most effective. So, make sure you are working with a mental health provider, or psychiatrist, who’s experienced in treating all levels of depression, anxiety and PTSD. And don’t hesitate to contact our mind and body clinic at 612.682.4912 to set up an in-person or telehealth appointment with Dr. Brian Johns.