When other treatments fail, deep-brain stimulation (DBS) may offer hope to patients suffering from chronic and severe depression, according to a study presented here at the 76th Annual Meeting of the American Association of Neurological Surgeons (AANS).
New developments. The oldest form is ECT, newer forms of neurostimulation: deep brain stimulation, rTMS, VNS, tDCS, MST.
Vermont, USA (With an interview of Anne Donahue)
Vermont hospitals bring back ECT therapy to treat depression
Hulp Gids, The Netherlands
Found a new recent blog called Electroconvulsive Therapy, all about…. you guessed it.
It has a recent post on cognitive side-effects with ultrabrief stimulus. The results were presented as a poster at the European congress of psychiatry of the AEP in Nice, France, 4-9 April.
We concluded that bifrontal and unilateral ultra-brief pulse ECT are effective treatment techniques that do not cause measurable cognitive side-effects or cognitive complaints.
The author also has a blog called: A day in the life of a shrink. It is in Dutch or should I say Belgian.
Another open labeled trial with rTMS. It is a continuation trial after a recent double-blind placebo controlled trial with rTMS.This study is discussed in a recent post on this blog: Finally some good news about rTMS?
Considering the outcome on the time point at week 4, Dr Shock is not very impressed by the results. For significant difference with the primary outcome 6 patients had to be excluded from the analysis. The mean difference between active and sham on the severity scales is in the range of 2-3 points, significant but hardly clinical relevant.
The NICE guidelines use a difference of 3 point or more as clinical significant.
Another open trial is unethical to my opinion in this stage of development of rTMS.
Patients that were non responders on the double-blind sham controlled rTMS trial received an additional 6 weeks of active rTMS. The nonreponders on the active rTMS group also were continued on rTMS for 6 weeks. Both patients and investigators remained blind to prior treatment condition. The open label study had 2 phases: a 6 week antidepressant medication free acute phase treatment and a 3 week taper phase during which antidepressant medication was initiated. Patients received 5 rTMS sessions per week during 6 weeks followed by 3 times a week in week 7, 2 times a week in week 8 and once a week in the last week.
Patients who received sham in the preceding randomized controlled trial (N = 85), the mean reduction in MADRS scores after 6 weeks of open-label active TMS was -17.0. Further, at 6 weeks, 36 (42.4%) of these patients achieved response on the MADRS, and 17 patients (20.0%) remitted. Remission was defined as a score under 10 on the MADRS. For those patients who received and did not respond to active TMS in the preceding randomized controlled trial (N = 73), the mean reduction in MADRS scores was -12.5, and response and remission rates were 26.0% and 11.0%, respectively.
A well just to let you know, we will wait for another open label trial.
What is interesting to know is that in in the sham to rTMS treatment group, failure to only one antidepressant trial before rTMS resulted in a greater likelihood of response. If resistant to more antidepressants before rTMS predicted less favorable outcome.
When is there going to be a sham controlled trial without medication resistant depressive patients?
You can read the abstract of this article on Therapeutic Neuromodulation Weblog
Avery, D.H. (2008). Transcranial magnetic stimulation in the acute treatment of major depressive disorder: clinical response in an open-label extension trial.. Journal of Clinical Psychiatry, 69(3), 441-451.
This is the title of an article in the Washington Post online. Another with opinions from different professionals, psychiatrists and psychologists alike as well as patients view. This article put’s ECT in a historic perspective and also discusses a recent article in the JAMA which is described in this blog a few day ago.
This blog about depression and it’s treatment especially with ECT is in the air for a while. I hope a lot of readers benefit from these scribbles. The truth be told, I learn a lot from writing these articles. Mostly I gather a lot of information for my work as a psychiatrist which end somewhere in a drawer or the “round archive” without being read at all. Since writing this blog I actually read them and when appropriate post the information on my blog. Surfing on the net nowadays is always accompanied by the question: Is this information relevant, blogable?
Now I take the privilege today to look back on my posts and make a round up of the most important sites with information about ECT relevant for interested readers in this subject, hope you like it.
1. About ECT for bipolar disorder from healthyplace.com, also more general information about ECT, the procedure, side effects.
2. Take it easy on ECT. Opinion of a patient treated with ECT about the side effects and the discussions about this topic in the media.
3. Another patient’s opinion about ECT and it’s side effects adding to the discussion in the media.
4. Electroconvulsive therapy (ECT): Treating severe depression and mental illness. Information by the Mayo Clinic. Very informative for patients facing the choice.
5. ECT get’s a makeover. On ABC News, the opinion of patients and doctors.
A commentary in the JAMA by Prof Max Fink. In this commentayr he sumarizes the most important recent topics in ECT.
1. Remission for depressive illness with ECT: 55%-86%, these results compare favorably to the response rates in the STAR*D trial.
2. Relapse prevention after ECT, nortriptyline with lithium is first choice, continuation ECT for patients who relapse despite this treatment and for those who may not tolerate medication.
3. ECT is a primary treatment for psychotic depression.
4. ECT reduces the acute risk for suicide.
5. Medication resistance does not bare relation to treatment efficacy with ECT.
6. He still favours bilateral electrode placement.
7. Important side effects are anterograde-, retrograde amnesia.
8. Vagus Nerve Stimulation and Deep Brain Stimulation are not comparable in efficacy to ECT.
This is in short his few about the recent achievements in ECT treatment and it’s research. His preference for bilateral ECT is a topic for debate. Unilateral electrode placement is technically more complex but comparable in efficacy when done the right way. That is with supratreshold stimulus dosage after stimulus titration during the first session. Research with side effects should be done for the long term and focussed on individual differences
Cyberonics Inc. on Monday said the United States Food and Drug Administration has approved its Demipulse and Demipulse Duo generators for commercial release. The products are used for vagus nerve stimulation, which is used in the treatment of epilepsy and certain types of depression.
In August 2006 Cyberonics saw the FDA reject the company’s application to use its implantable generator to treat depression in patients who do not respond to medications. Mainly due to disappointing results of clinical trials. In the only randomized controlled trial VNS failed to perform any better when turned on than in otherwise similar implanted patients whose device was not turned on. For summary of safety and effectiveness data see this FDA rapport.
The pacemaker-like device, which is surgically implanted into a patient, has been available in the U.S. since 1997 as a treatment for epilepsy.
VNS uses a stimulator that sends electric impulses to the left vagus nerve in the neck via a lead implanted under the skin. The left vagus nerve is stimulated rather than the right because the right plays a role in cardiac function such that stimulating it could have negative cardiac effects. The exact method of therapeutic action is unknown, but VNS has been shown to affect blood flow to different parts of the brain, and affect neurotransmitters including Serotonin and Norepinephrine which are implicated in depression. Some patients experience an alteration of voice quality and loudness during the time that the pulse is being delivered to the vagus nerve. Other common side effects include hoarseness, throat pain, cough, shortness of breath.
For further eading on VNS please see Wikipedia.
For more explanations about the differences between VNS, Magnetic Brain Stimulation and Deep Brain Stimulation, please see this website from Biotele.
For more information about VNS see this page from the Mayo Clinic. And this one for Deep Brain Stimulation.
My opinion is that efficacy is not proven for these treatments for depression although there are patients that can benefit. Before you try one of these methods be sure they have been treated with all regular options including ECT or electroshock.