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Advances in the Treatment of Depression: Brain Stimulation

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Descartes Li

on 13 September 2014

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Transcript of Advances in the Treatment of Depression: Brain Stimulation

Brodmann Area 25
(subcallosal cingulate gyrus, SCG)
and others
Brain Stimulation
Electroconvulsive Therapy (ECT)
Deep Brain Stimulation (DBS)
Transcranial Magnetic Stimulation (TMS)
Nuland, M.D.
deep brain stimulation
transcranial magnetic
electroconvulsive therapy
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
Target: DLPFC
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
Moderately effective
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)
no seizure
5d/week, 40min per session
30-40 treatments
Primary indication is anesthesia
Ketamine is under very active investigation
not FDA approved for depression
not FDA approved for depression
Tw: @DescartesLi
side effects
muscle aches
post-treatment confusion
memory impairment

[rarely, mania/hypomania]
General Description
6-15 treatments
usually done 3X/week
entire procedure is 30min
one hour preop
1-2 hour recovery
Office treatment
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
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