Emerging Antidepressants: What Clinicians Can Expect

In this Q&A, Charles DeBattista, MD, DMH, professor of psychiatry and behavioral sciences and director of the Depression Research Clinic at Stanford University School of Medicine, talked with Psych Congress Network about his Psych Congress 2022 session “State of Depression.”

As more treatment options become available, Dr DeBattista discusses the limitations of many current antidepressants, why these emerging medications are different, and what clinicians can do in the meantime.

This interview has been edited for clarity.

Question: In your session, you discussed the limitations of most current antidepressants. What do emerging treatments offer that existing or legacy treatments do not?

Answer: Despite the availability of over 30 antidepressants, we still have far too many patients that do not adequately respond to or tolerate the available treatments. Oral monoamine antidepressants have been extremely helpful to many patients, but depression is a heterogeneous illness, and there are likely many different biological drivers of depression than can be adequately addressed with one predominant mechanism. Thus, having new options that work differently than the current medication may help many patients whom the available medications do not. In addition, the medications under evaluation now tend to be far faster acting than legacy medications and may require only limited or intermittent administration to achieve longer-term benefits.

Question: What key treatment options are emerging in the field that will help clinicians treat patients’ individual needs and side effects?

Answer: The large range of medications in development with novel mechanisms, each with a different side effect profile, will provide clinicians with more options to enhance outcomes. New technologies will gradually emerge that assist clinicians in matching the best treatment for a specific situation. We are not quite there yet. However, biomarkers such as pharmacogenomic tests that may help clinicians better predict the tolerability and efficacy of a specific agent to a specific patient are evolving. We also continue to evaluate imaging technologies that may help us improve outcomes with transcranial magnetic stimulation (TMS) and pharmacotherapies. In the meantime, there is no substitute for doing a detailed history to evaluate the presence of depression subtypes, rule out co-morbidities, and carefully assess the efficacy and adverse events of each past treatment.

Question: What key steps can clinicians take to promote patient engagement and adherence in treatment plans?

Answer: The challenges of maintaining engagement of patients with some of the new medications including psychedelics, esmethadone, and zuranolone are not dissimilar to what we do currently as clinicians to promote a therapeutic alliance. These include education about the risks and benefits of a given treatment, setting realistic expectations, and maintaining close monitoring of the patient, particularly early in the course of treatment. We want to encourage patients to reach out to us for questions or concerns that arise as a new treatment begins. It is also important to always provide hope and the expectation that the patient can get better and that we will be with them in pursuing this objective. It is important not to buy into the nihilism that many more severely or chronically depressed patients experience. It is often devastating for patients when their clinician runs out of options or conveys a sense of hopelessness about their chances for recovery. There are always other things to try.

Question: Are there any misconceptions surrounding this topic that you would like to clear up?

Answer: New treatments are often met with apprehension as well as hype and hope. Both the hope and fears about treatments such as psychedelics, esmethadone, novel TMS strategies, etc., are often inconsistent with the available data. We currently do not have enough information to be either concerned or overly enthusiastic about any of these treatments. While I am cautiously optimistic that some of these treatments will work out, we need time to vet these strategies with careful studies.

Charles DeBattista, DMH, MD, is a professor of psychiatry and behavioral sciences at Stanford University School of Medicine. In addition to serving as director of medical student education in psychiatry at Stanford, he also is the director the Depression Research Clinic and co-section chief of the Mood Disorder Clinics. Dr DeBattista received his doctorate in mental health and doctor of medicine degrees at the University of California, San Francisco. He later went on to complete his psychiatric residency at Stanford University, where he served as chief resident and later as a fellow in psychopharmacology.

Dr DeBattista’s research interests include the pharmacotherapy of severe and resistant depression, biomarkers that predict antidepressant treatment response, and devices in the treatment of major depression.