Conditions: what treats what — honestly

Depression and treatment-resistant depression (TRD)

Major depression is a whole-body, whole-life illness: mood, sleep, appetite, energy, concentration, sex drive, memory, and hope all run through circuits tied to the brain's front control area. It is not laziness and it is not a choice.

The ladder, in brief (full version on Candidate & Cost): confirm the diagnosis first — depression that does not respond sometimes turns out to be bipolar depression, hypothyroidism, sleep apnea, anemia, chronic pain, grief, a substance, or another medicine. Then a first adequate medicine trial, then a switch or an add-on. Two adequate failures = treatment-resistant depression. That is the doorway to Spravato, to TMS authorization, to augmentation strategies, and to ECT at the severe end. “Resistant” describes the illness's response so far. It says nothing about the patient, who usually did everything asked.

Where TMS and Spravato fit: both are depression treatments with their strongest evidence exactly here — TMS cleared after inadequate antidepressant response, Spravato approved for TRD, including as monotherapy since January 2025. Response means at least a 50% drop in the symptom score (PHQ-9); remission means the score is in the near-zero range and life is functioning again. Ask at every visit: “What is my score today, and what was it when we started?”

PTSD — trauma-focused therapy is first-line

The four clusters

• Re-experiencing: intrusive memories, nightmares, flashbacks, intense reactions to reminders. The memory has no date stamp, so the body reacts as if it is in danger, not recalling it.
• Avoidance: steering around places, people, conversations, smells, news, paperwork, exams, intimacy. It works for ten minutes and costs a life over ten years — the world shrinks, and the fear never updates. From outside it can look like stubbornness or not caring. It is neither.
• Negative changes in mood and thinking: shame, guilt, blame, feeling cut off, losing interest, being unable to feel positive emotions, holes in memory of the event. This is where PTSD and depression fuse.
• Hyperarousal: startling at ordinary sounds, scanning rooms, irritability, broken sleep, concentration shattered by constant sentry duty. That exhaustion is medical, not moral.

During overwhelming danger the brain stores the event as sensory fragments — a sound, a cologne, a phrase, a body sensation — tied directly to the survival response, bypassing the slower time-stamping parts of memory. That is why “just calm down” and “that was years ago” fail: the alarm fired before the reasoning brain could check. Every treatment that works helps the front-brain checking system get stronger and helps the memory get re-filed as a memory — in the past, survivable to recall. Read Brain & Trauma for the full neuroscience.

What treats PTSD at its root

Every major guideline, including VA/DoD, puts trauma-focused psychotherapy ahead of medication: Cognitive Processing Therapy (CPT, about 12 sessions), Prolonged Exposure (PE, about 8–15 sessions), EMDR, and trauma-focused CBT. No pill, spray, or magnet has evidence as a standalone root treatment for PTSD that matches these therapies.

Medicines for PTSD

• Only two medicines carry FDA approval for PTSD: sertraline and paroxetine. Fluoxetine and venlafaxine are also guideline-supported first-line options. Expect modest average benefit — real, worthwhile, usually partial. Medicines take the edge off so therapy becomes possible; they rarely resolve PTSD alone.
• Prazosin for nightmares: off-label, evidence genuinely mixed (a large VA trial was negative overall); an option to discuss, taken at bedtime because it can drop blood pressure. Imagery rehearsal therapy and sleep-focused care belong in the same conversation.
• Benzodiazepines are specifically not recommended for PTSD: no proven benefit for core symptoms, they can strengthen avoidance, carry dependence risk, and appear to interfere with the learning trauma therapy depends on. Never stop one suddenly — plan a slow taper with the prescriber.
• Antipsychotics are not a main PTSD treatment: a large risperidone add-on trial did not beat placebo; guidelines recommend against antipsychotic monotherapy for PTSD.

A strong combined PTSD plan has four legs: (1) trauma-focused therapy started or firmly scheduled; (2) a first-line medicine at a full dose for a full trial; (3) targeted help for the worst remaining symptoms — sleep and nightmares by name; (4) where severe depression also qualifies, an interventional treatment chosen with open eyes. Safety, substance use, sleep apnea screening, and a crisis plan run underneath all four.

Anxiety

“Anxiety” can mean several different things, and the treatment follows the meaning:

• Anxious depression — worry, tension, and dread layered on a depressive episode. This is the one form with a TMS clearance (BrainsWay and NeuroStar, as a depression clearance that includes reducing accompanying anxiety symptoms).
• Generalized anxiety disorder (GAD) — hard-to-control worry most days, with muscle tension, fatigue, concentration trouble, irritability, broken sleep.
• Panic disorder — sudden surges of intense fear peaking in minutes, plus dread of the next surge.
• Social anxiety disorder — intense fear of scrutiny or rejection, with avoidance that costs jobs, schooling, and relationships.
• OCD is classed separately, travels with anxiety, and has its own TMS clearances — after standard treatment, which is exposure and response prevention (ERP) therapy, often with an SSRI at higher doses and longer trials.

What treats anxiety: therapy — especially CBT — is first-line for every anxiety disorder above. First-line medicines are SSRIs and SNRIs, often needing eight to twelve weeks at a therapeutic dose; the first one to two weeks can temporarily raise jitteriness, which is why starting low and warning in advance matters. Buspirone is a gentle, non-habit-forming GAD option (slow, not a rescue medicine). Supporting players include hydroxyzine, gabapentin/pregabalin (off-label, taper required), propranolol for the body symptoms of performance anxiety only, and mirtazapine or trazodone where anxiety, insomnia, and poor appetite arrive together. Benzodiazepines have a narrow, time-limited role at most — see the Compare page.

Cigarette smoking

Nicotine reaches the brain in seconds and triggers dopamine in the reward circuit. Each cigarette pairs that signal with a cue — coffee, driving, stress, a meal, a doorway — until the cues alone fire craving. Add chemical withdrawal (irritability, anxiety, low mood, hunger, poor concentration, insomnia) peaking in the first week, and quitting is a circuit problem plus a dependence problem, not a knowledge problem. Treatments that work attack both halves.

Even with the best single medicine plus counseling, roughly one in four to one in three people are smoke-free at a year in trials, and most people who quit for good took several attempts. A failed attempt is data, not a verdict on the person.