The UC Davis Department of Psychiatry and Behavioral Sciences recently opened a new Advanced Psychiatric Therapeutics (APT) Clinic in Sacramento, dedicated to treating patients with treatment-resistant depression.
The APT Clinic provides the novel treatment modalities transcranial magnetic stimulation (TMS) and esketamine nasal spray. It opens at a time when medication and technology have made major improvements in recent years: treatment response rates with TMS and esketamine are up to 70%, while electro-convulsive therapy (ECT) — also to be offered through the clinic in the future — has shown up to an 85% response rate in patients with refractory major depression.
“Depression is one of the most common psychiatric disorders. It spans all life stages and can be debilitating and even life-threatening,” said Helen Kales, M.D., the Joe P. Tupin Professor of Psychiatry and chair of the Department of Psychiatry and Behavioral Sciences. “While antidepressant medications and therapy are effective in many patients, they don’t work for everyone.”
New hope
TMS and esketamine may offer hope for patients with treatment-resistant depression or those for whom antidepressant medications are only partially effective or intolerable.
TMS is a non-invasive treatment that uses gentle pulses of magnetic fields to stimulate nerve cells in the brain. It works differently than standard antidepressant medications, like serotonin reuptake inhibitors (SSRIs), and without their undesirable side effects such as weight changes and sexual dysfunction. The FDA has also approved TMS for obsessive-compulsive disorder (OCD) and migraines.
Patients will generally receive daily treatments for the first six weeks, followed by a three-week taper phase in which frequency is gradually reduced to once per week before completion. Treatment durations generally last from five minutes to 30 minutes, depending on the individual patient.
Although TMS was first approved for treatment in 2008, the technology has evolved and improved significantly since then, according to Debra Kahn, M.D., professor and clinical psychiatrist in the Department of Psychiatry and Behavioral Sciences and director of the new APT Clinic.
Esketamine (brand name Spravato®), an FDA-approved nasal spray derived from ketamine, is thought to improve symptoms of depression by helping to restore connections between nerve cells in the brain. Esketamine is administered under supervision in a clinic due to the potential for side effects including sedation or dissociation.
Patients will typically receive treatment twice weekly for the first month, once weekly for the second month, and once every one to two weeks for maintenance. During clinic visits, patients self-administer the nasal spray medication and then spend a couple of hours in a relaxing environment while it takes effect. Results can be rapid, with some patients feeling improvement within days.
Candidates for these treatments are adults who have tried two other antidepressants without significant improvement. Physicians work with patients to determine eligibility, and discuss risks and benefits before formulating treatment plans.
“Depression is, unfortunately, a common and potentially devastating illness, and it’s becoming more common each year in the United States,” said Katharine Marder, M.D., a UC Davis Health psychiatrist who specializes in treatment-resistant depression. “While medications and talk therapy are effective treatments for many people, we also know that one in three people with depression won’t respond to those standard treatments.”
“As a provider, it’s sad and frustrating when you have patients who have been depressed and are not getting better,” Kahn added. “It’s exciting to have these new treatment options, and it makes us feel hopeful that we can help people that we haven’t been able to help before.”
Intravenous ketamine, psychedelics research also on tap
The clinic’s current home in the Lawrence J. Ellison Ambulatory Care Center is temporary, with a 15,000-square-foot permanent space at East Sacramento’s Cannery Business Park expected to open next year following a $20 million renovation. The clinic will accommodate more patients and offer expanded treatments after the move, with more TMS machines plus intravenous ketamine in addition to nasal spray.
It will also engage in clinical trials, such as investigations of new TMS algorithms that utilize functional neuroimaging to identify treatment locations, and surgical interventions for refractory major depressive disorder in concert with UC Davis Health’s Department of Neurosurgery. The APT clinic will also support trials of psychedelics and non-hallucinogenic psychedelic analogues, the latter in collaboration with the UC Davis Institute for Psychedelics and Neurotherapeutics.
Although there are many promising new treatments, the clinic is taking an evidence-based approach to potential new therapies.
“New psychiatric interventions, including psychedelics and other novel neurotherapeutics, offer a lot of hope for people struggling with mental health disorders,” Kales said. “Hope is great, but we need the evidence to back it up. With the new clinic, we will be able to evaluate the potential effectiveness of these new treatments.”
In addition to Kales, Kahn, and Marder, TMS-certified psychiatrists at the new clinic are John Onate, Lorin Scher, Amy Barnhorst, James Alan Bourgeois and Manpreet Singh. Additional care team members include Matthew Settle, a psychiatric nurse practitioner; Donna McDonald, a nurse manager; and Leticia Diaz and Mary Lomu Lilomaiava, TMS technicians.
