Over the past ten years, the rate of depression has increased drastically within the United States. Research suggests that depression can be caused by a number of factors, including genetics, the environment, and life experiences. Symptoms are presented differently in different people. Some common symptoms are persistent sad or anxious moods, feelings of hopelessness, irritability, lost of interest in hobbies/activities/relationships, appetite or weight changes, and thoughts of death/suicide. (This being said, please, if any of these symptoms are consistent within yourself or someone you know, talk to someone/them and get help.)
On a more positive note, the number of new medications to treat depression has multiplied, and a variety of antidepressant medications now exist. However, a large number of patients with depression still struggle to find relief. According to a STAR*D trial, by the National Institute of Mental Health, more than half of patients with depression do not respond well to their first medication, and up to a third of patients with depression do not find relief even after multiple subsets of medications. These patients who do not respond to multiple antidepressants or cannot tolerate medication side effects can have treatment-resistant depression. Although this can be difficult, Sibley Memorial Hospital, Johns Hopkins Medicine, has developed a Psychiatry and Behavioral Health Program where two noninvasive procedures have been documented as successful with regards to treatment-resistant depression. According to Erica Richards M.D. Ph.D. of Sibley, the two therapies, transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT), are able to aid those who have not benefited from medications.
Transcranial Magnetic Stimulation (TMS)
TMS is a noninvasive procedure that uses magnetic fields to stimulate certain nerves and pathways to improve symptoms of depression. TMS is used when other medications such as antidepressants are not effective.
Repetitive transcranial magnetic stimulation (rTMS) isn’t invasive, and is usually done on an outpatient basis in a doctor’s office or clinic. Before having rTMS, patients will need a physical exam, to ensure rTMS is an appropriate treatment option, and a psychiatric evaluation, to discuss his/her depression because symptoms of psychosis will prevent successful rTMS treatment.
During the first treatment, an electromagnetic coil will be placed on the head and switched off and on to produce stimulating pulses. Patients will feel gentle tapping and clicking; this process is called mapping. Then, the doctor will determine the amount of magnetic energy needed by increasing the pulses until the patients fingers start to twitch. Further treatment is expected to improve depression symptoms within 16-20 sessions. During normal sessions, the treatment coil is placed on the left temporal region of the brain, which is linked to mood control. The pulsing of magnetic fields turn on and off rapidly to produce lasting changes within brain circuits and activity to improve mood and ease depression symptoms. The procedure lasts for 40 minutes, and the patient will remain awake and responsive. Post treatment, patients will be able to return to daily activities immediately.
The risks associated with rTMS are very low due to it being a noninvasive form of treatment, and thus, not requiring surgery, anesthesia, or implantation of electrodes. Some common effects of the treatment are headaches, scalp discomfort, lightheadedness, and tingling of facial muscles. Some serious uncommon effects of the treatment are seizures, mania, and hearing loss. Generally, rTMS is considered very safe in the short term although long term effects have not yet been researched.
rTMS is proven to be a short term solution, and several clinical trials are exploring whether rTMS can become a long term solution for depression.
Electroconvulsive Therapy (ECT)
ECT is another form of therapy for patients with treatment resistant or severe depression. It, however, is invasive, and patients undergo general anesthesia. ECT is a procedure wherein small electric currents are passed through the brain, triggering seizures that momentarily reroutes the brains chemistry to reverse symptoms of certain mental illnesses.
Before starting treatment, patients are required to undergo a full evaluation: a medical history, a complete physical, basic blood tests, a ECG, and an anesthesiologist review. When the procedure is done, patients will have general anesthesia, an IV line, muscle relaxants and electrode pads on the head. To keep track of seizures, doctors will place a blood pressure cut off around the ankle to stop the relaxant from entering the foot and to watch for movement within that foot. In addition, heart, breathing and oxygen monitors will be used for patient safety.
At the start of the procedure, the doctor activates the ECT machine inducing a seizure that lasts less than 60 seconds. Due to the anesthesia and muscle relaxant, the only indication the patient is having a seizure is the movement of the foot. Inside the brain, activity increases drastically during the seizure and levels out after; the seizure is monitored with a EEG (electroencephalogram).
Most people start to see results after 6 treatments; however, it is recommended to complete a total of 12 treatments.
The stigma behind ECT is due to previous methods of electric shock induced without general anesthesia, leading to memory loss and confusion. Today, in a controlled environment and with updated technology, ECT is very safe and successful. Some rare serious risks involved include confusion, memory loss, and medical complications.
Furthermore, ECT can be used for other illnesses other than depression. For instance, ECT can help patients with severe mania, a state of euphoria associated with bipolar disorder, catatonia, lack of movement or strange behaviors, and agitation, in people with dementia.
Currently, many clinical trials at Sibley Memorial, NIH, Mayo Clinic (etc) are looking for further ways to reduce the burden of depression. Depression is very common, and the scientific community is striving towards more remedies and publications.
References and Footnotes:
“Resetting the Brain.” Sibley Memorial Hospital Johns Hopkins Medicine. June 2018. Print. 21 June 2018.
“Electroconvulsive Therapy.” Mayo Clinic. Web. 20 June 2018.
“Transcranial Magnetic Stimulation.” Mayo Clinic. Web. 22 June 2018.