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Advances in the Treatment of Depression: Brain Stimulation
Transcript of Advances in the Treatment of Depression: Brain Stimulation
(subcallosal cingulate gyrus, SCG)
Electroconvulsive Therapy (ECT)
Deep Brain Stimulation (DBS)
Transcranial Magnetic Stimulation (TMS)
deep brain stimulation
Prudic J et al. Effectiveness of Electroconvulsive Therapy in Community Settings. Biol Psychiatry 2004;55:301-312.
Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006;63:1337-44.
Nelson, J. Craig. The STAR*D Study: A Four-Course Meal That Leaves Us Wanting More. Am J Psychiatry 2006 163: 1864-186.
Recent Efficacy Rates
The UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361: 799–808
ECT vs. Antidepressants
Currently in clinical testing phase
Advances in the
Treatment of Depression:
Case series in chronic pain
in terminally ill
NMDA receptor antagonist
Zarate et al. A Randomized Trial of an N-methyl-D-aspartate
Antagonist in Treatment-Resistant Major Depression. Arch Gen Psychiatry. 2006;63:856-864
Tapping noise – Use earplugs
Prickling sensation on the scalp
Transient headache (<10%)
Mild analgesics effective
8 reported seizures during early rTMS
No significant cognitive, cardio problems
rTMS Side Effects
3 randomized, non-blinded, non-placebo controlled studies rTMS vs. ECT
Patients ill enough to justify ECT
3-4 weeks of treatment
Close or equivalent for uncomplicated depression(?)
ECT superior for psychotic depression
Relapse rates similar at 6 months (~20%)
rTMS compared with ECT
rTMS for depression > effective than sham
Effect size of ~ .65 on average
How Effective, and for What?
Patient sits or reclines in chair
Headrest / earplugs
Application of a localized magnetic field to the scalp
Magnet powered by high-intensity electrical current
Magnetic field induces local electric currents in superficial cortex (2-3 cm)
5d/week, 40min per session
Primary indication is anesthesia
Ketamine is under very active investigation
not FDA approved for depression
not FDA approved for depression
usually done 3X/week
entire procedure is 30min
one hour preop
1-2 hour recovery
Non-invasive, No anesthesia
Patient awake, alert
1940: Kalinowsky introduces ECT to the U.S.
1934: camphor replaced by pentylenetetrazol (Metrazol)
1938: Cerletti and Bini use electricity to stimulate seizures.
History of ECT
1932: Ladislav Meduna observed cell over- and under-growth in brains
1933: Animal trials to find medication that could reliably induce seizures
1934: First trial of camphor induced seizures in humans