What do psychiatrists recommend when results are needed fast?

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Antidepressants take 12 weeks to see the full effect of a dose. Mood stabilizers can work within a few weeks, but often require titration schedules like Lamotrigine. Antipsychotic medications work pretty fast giving some immediate relief, but if you have a person who is very acutely psychiatrically ill, the fastest acting options are ketamine and ECT. They can work within hours of administration. Yes, we still do ECT. It’s a very effective treatment option. Does it come with side effects? Yes, of course. The side effects are less than what they used to be because we now use ultra brief pulse dosing instead of a steady current, but they are still there. I would say 99% of my ECT cases were patients requesting them. It’s especially helpful for older people who are no longer responding to medications. Both ketamine and ECT have to be used with caution in people with bipolar disorder because they both can precipitate hypomania or mania.

On the horizon, lessons from treating postpartum depression. Brexanolone and Zuranolone are both FDA approved for treatment of postpartum depression, but they were initially being developed as treatments for depression. Both are very fast acting with a mechanism similar to ketamine, but without the side effect of hallucinating. My hope is that the FDA will eventually approve these medications for depression as well and give us access to more fast acting options. These medications work within hours to days as does ketamine and ECT.