Depression

Treatment of Depression

Depression is an extremely complex condition that can profoundly affect the lives of those who suffer from it. Although the diagnosis and treatment of its various forms have become more sophisticated over the years, there still remain many significant challenges to be faced when it comes to providing effective care for people struggling with this debilitating disorder.

Treatment of depression is a Specialization within a Specialization and integrates different skills, for example, in clinical psychiatry, pharmacology, neurophysiology, and neuroimmunology. Often treatment for Treatment Resistant Depression follows the guidelines for NON-Treatment Resistant Depression and remains at a General Psychiatry, nonspecialized level.

Why do innovations in treatment come so late?

Unfortunately, Italy sees insufficient consideration for Depression, despite the fact that the World Health Organization (WHO) considers it the most important health problem worldwide. More specifically, Italy was the last among the European countries to guarantee reimbursement for Depression treatments carried out using SSRI drugs after the year 2000. Dr. Stefano Pallanti, on the other hand, had begun administering these off-label medicines to his patients as early as 1984, proving to be a pioneer in the treatment of depression.

Toward specialized care

To move beyond the approach set by the essential General Psychiatry of the Italian National Health System, it is necessary to ensure a second and third level of specialized care.

➜ The first level of care is characterized by the intake interview and prescription of the treatment: without other assessments, definitions of the individual diagnosis and specific examinations. This is the only level of care adopted by the Italian National Health System to guarantee the essential levels of care.

➜ The second level of care is characterized by the detection of the subtype of depression, the measurement of severity and degree of resistance of the disorder. Within this level of care, consideration is also given to any other possible disorders in comorbidity, and close monitoring of care is undertaken with particular attention to the early stages of response, even better if in a Day-Center setting.

➜ The third level is characterized by the addition of specific tests, including metabolic assessments, absorption levels, and, if necessary, a genetic investigation. Finally, this level of care involves the use of innovative therapies validated by scientific research but not yet included in the essential guidelines. These include Neuromodulation Therapies and in particular Transcranial Magnetic Stimulation (TMS) combined with Neuronavigation which allows to stimulate target circuits defined for each person. Alongside these treatment processes, treatments dedicated to metabolic, inflammatory and microbiome rebalancing are also integrated.

Accurate diagnosis for effective treatments

Depression is more than just a "depressed mood." It can manifest itself in different ways and often occurs in combination with other medical conditions or mental disorders, including ADHD, Autism, Anxiety Disorders, Obsessive-Compulsive Disorder, Substance Addictions, Somatic Symptom Disorder, Fibromyalgia, PANS-PANDAS, Parkinson's Disease, Schizophrenia and other medical conditions. This makes the diagnosis and treatment of depression a complex task that requires a multidisciplinary approach.

In addition to this, depression is a major cause of disability worldwide and a major contributor to the overall global burden of disease.

To adequately address the complexity of depression, a personalized approach is needed. This starts with an accurate diagnosis, using high-level tools to identify the subtype of depression, specify the characteristics of the disorder, and identify comorbidities from the very beginning of the care pathway. In the case of depression, these aspects are crucial because the treatment of the depressive episode differs from subtype to subtype and also varies widely depending on whether other psychiatric or medical disorders are associated.

Diagnosis is the necessary starting point for effective treatment, so the more precise the better; however, it is only the beginning of the person's intake pathway, whose treatment must be person-centered and not exclusively symptom-centered. This is because symptoms do not define the diagnosis, and the diagnosis does not directly define the treatment. For example: the symptom "Depressed Mood" takes on different meanings as a result of the different dysfunctions that may underlie it, and must therefore be treated specifically depending on the precise dysfunction behind it.

Specifiers to define subtypes of Major Depression

What are Specifiers? They are extensions of a diagnosis useful to precisely define a disorder or disease. They allow a more specific diagnosis to be made: the specifier identifies a set of symptoms associated a specific biology, so particular that the treatment is different for each of these forms.

The specifiers provided for Major Depressive Disorder (MDD) within the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) distinguish the following forms of the disorder:

• With anxious distress;

• With mixed features;

• With melancholic features;

• With atypical features;

• With mood-congruent or mood-incongruent psychotic features;

• With catatonia;

• With peripartum onset;

• With seasonal pattern.

In addition to these subtypes of depressive manifestations, it is important to keep in mind that if a depressive episode occurs in the context of a Bipolar Disorder ― configuring as "Bipolar Depression" ― it will require an entirely different intake and treated differently from other depressive conditions.

Other in-depth investigations

In addition to the specification of the observed subtype of depression, it is important not to limit oneself to the overt symptoms but also to consider the medical conditions and personal biological factors of the individual patient, paying particular attention to the developmental features of the disorder, neurofunctional correlates, cognitive functioning, and inflammatory response.

Only through an integrated, multidisciplinary approach is it possible to provide effective treatment for those struggling with depression. For this reason, the assessment of the disorder must include investigation of:

• Degree and type of resistance of the disorder;

• Current psychiatric comorbidities;

• Status of comorbidities in Neurodevelopment and ADHD;

• Medical comorbidities that could reduce response to treatment;

• Metabolic aspects;

• Inflammatory and immune response;

• Degree of drug absorption;

• Gut microbiota.

The investigation of these areas is essential for proper care planning that takes into consideration all the possible conditions that may infuence response to treatment or require specific therapeutic interventions.

Preventing Resistance

Once the diagnosis of depression has been defined, it is critical that treatment be undertaken as soon as possible and closely monitored to be able to assess the initial response to treatment.

Treatments for depression must be varied based on the specific clinical presentation and person-centered. The goals of treatment must be shared and targeted to the specific causes of the disorder in that person, with the primary goal of restoring the balance between central nervous system plasticity and the inflammatory response, while promoting metabolic, inflammatory, and gut microbiome rebalancing.

Such an approach involves an ongoing process of treatment evaluation: if the treatment does not seem to be working or has achieved only a mild initial effect and then stopped acting positively, it may be necessary to reevaluate the diagnosis in order to better frame the therapy and reduce the likelihood of resistance and relapse. If new aspects emerge during the treatment process that require clinical attention, it is then important to widen the focus and consider other treatable aspects.

Combined or stand-alone therapies

Treatment of Depression and Resistant Depression can include different forms of therapy targeted to the specific causes of the disorder: pharmacological tharapies, natural cures, neuromodulation therapies, and psychological interventions.

In the treatment of depression, what really makes the difference is NOT the drugs or machines, but the physician's ability to choose, calibrate and share with the patient the specifically tailored treatment plan based on careful assessment.

Precision psychiatry is exactly this: for each person, a treatment designed ONLY for him or her.

All therapies offered by the Istituto di Neuroscienze are scientifically validated, many of them already approved by the FDA. In addition to these, we also offer the opportunity to receive cutting-edge therapies not yet included in the essential guidelines, namely "off-label" therapies. Find out what off-label treatments are ➜

Our Therapies

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Neuromodulation Therapies

Neuromodulation Therapies represent an advantageous alternative to traditional medical treatments because they can be combined with each other and associated with additional medical and psychological therapies in order to achieve a highly personalized treatment.

Moreover, they are free of side effects. Read more in this page!

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Intravenous Therapy (IV Therapy)

For the treatment of Depression, Obsessive-Compulsive Disorder (OCD), Anxiety, Cognitive Disorders, and cases of drug resistance. Compared with traditional therapies, it allows greater tolerability, fewer side effects, and a generally shorter response time.

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Phytotherapy

Dr. Stefano Pallanti is a founding member of the italian Academy of Natural Therapy in Psychiatry and Neurology and promotes in an innovative way the use of natural remedies in psychiatry to offer alternative ― but scientifically proven ― treatments for the management of Depression, Insomnia and Anxiety.

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Diet and Nutrition

In recent years, the in-depth study of the gut microbiota has revealed its involvement in the translation of what we eat into the messenger-molecules for our brains, highlighting the strong correlation between diet and our state of well-being.

Find out what the Istituto di Neuroscienze can offer.

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The Role of the Gut Microbiota in Depression

Over the past few years, scientific research has made important progress in understanding the link between gut microbiota and depression. It has emerged that mechanisms potentially relevant to understanding depression exist in the microbiota―gut―immune response―brain axis. Indeed, it has been hypothesized that each different psychiatric disorder ― including depression ― may be associated with a specific alteration in the gut microbiota.

Numerous studies have confirmed the presence of significant changes in the gut microbiota in people suffering from depression. In addition, one study has shown that fecal transplantation from patients with Major Depression to healthy mice is capable of inducing the onset of depressive behaviors in rodents. Taken together, these findings suggest a critical role of the microbiota in emotional balance.

The good news is that early supplementation of prebiotics and/or lactoferrin glycoprotein is able to promote behavioral stress resistance and modulate gene expression in neural circuits involved in mood regulation. In addition, numerous studies have revealed that probiotics, antibiotics, and pathogenic bacteria can influence the gut microbiota and behavioral patterns of patients with depression.

These findings highlight the importance of increasingly considering gut health in the treatment of depression and open new paths for therapies involving the microbiota. The balance between our gut and our brain is a crucial aspect in understanding and treating depression and research continues to reveal new findings that may prove to improve the quality of life for people with this disorder.

In-depth Resources

Depression

This video collection on Depression explores the main features of this disorder and the most effective and innovative intervention methods for its treatment.

Watch and listen to Dr. Stefano Pallanti's interviews and speeches on the topic and to the contribution of some of our patients who provided their testimony regarding their treatment experience at our Institute.

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Esketamine for Resistant Depression

Discover Esketamine therapy for Treatment-Resistant Depression: a lifesaver for those who haven't responded to other treatments.

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Theta Burst Stimulation: A new treatment for Resistant Depression approved by the FDA

Discover the Theta Burst Stimulation protocol: an innovative method of Transcranial Magnetic Stimulation approved by the FDA for treating Resistant Depression, used by Dr. Pallanti since 2016.

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