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June 13, 2005

Brain Stimulation Alternatives for Depression

When one hear's about brain stimulation therapy they initially think of ECT or electro-convulsive therapy, but new types of brain stimulation therapies are coming out. They include rTMS, MST, VNS, and deep brain stimulation. Of course, all of these acronyms are meaningless without an explanation.

rTMS is repetitive transcranial magnetic stimulation, MTS is magnetic seizure therapy, VNS is Vagus nerve stimulation, and deep brain stimulation is just that. Although these procedures sound foreboding their therapeutical potential is undeniable.

In rTMS therapy "A magnetic coil is placed over the patient's scalp (specifically the left prefrontal cortex). The field passes unimpeded through the skull and induces an electrical current in the brain. There have been 62 published studies on 1,415 depressed patients showing 'a reasonable effect size.' Better results corresponded to longer courses, greater pulse intensity, and pulse quantity" (MacManamy 2005).

There are some side effects, the worst being unintended seizures. It is important to note that rTMS therapy is not FDA-approved and therefore is only investigational in the US. Canada has approved its use. rTMS is still being investigated for bipolar disorder.

MST or magnetic seizure therapy is another treatment for depression. "An investigational treatment, magnetic seizure therapy, uses rTMS technology to induce seizures. The effect is much like ECT, but because the current passes through the skull unimpeded, Sarah Lisanby MD of Columbia University explained at the APA symposium, it allows for more precise targeting into the brain. The aim is to induce seizures that do not spread to the motor cortex, thus sparing the memory regions of the brain. A study on primates showed better memory after MST than electroshock. Human subjects reoriented themselves much quicker after MST than ECT and experienced less retrograde amnesia. ECT had much better efficacy than MST in treating depression in academic settings, but was about the same in community settings. Dr Lisanby and her colleagues are currently experimenting with higher doses in primates"(MacManamy 2005). It is obvious that MST needs to be further studied before its effectiveness can be judged or before it becomes available in the United States.

Vagus nerve stimulation (VNS) is the closest to becoming FDA approved for treating depression in patients who have had difficulty responding to less invasive forms of treatment. A device that is similar to a pacemaker is inserted into the chest and sends a current up a wire that is connected to the vagus nerve. The vagus nerve is located at the bottom of one's skull and VNS activates various parts of the brain from the vagus nerve.

One company called Cyberonics did a study on the effectiveness of the product and found that it only helped about 30% of the VNS patients. "Cyberonics succeeded in convincing an FDA panel that 30 percent was an excellent result in light of the fact that this was a severely depressed population that had failed on all other treatments. Despite concern about the underwhelming response and the nature of the trial, the panel greenlighted the treatment for approval, with conditions. The FDA, however, rejected the panel's recommendation, then later reversed itself on receiving more data from Cyberonics, granting "approvable" status, one step short of 'approved.' One public interest group is urging that the FDA back away from final approval" (McManamy, 2005). The side effects are not too detrimental to the individual and only include hoarseness and vocal hiccups.

The last form of treatment to be discussed is called deep brain stimulation. In this form of treatment "Needle-like leads with four electrodes are inserted into targeted regions of the brain, guided by MRIs. An extension wire runs from each lead to one or more VNS-like devices implanted in the chest" (McManamy, 2005). This form of treatment is already FDA approved for treating Parkinson's and the potential benefits it can have for OCD and depressed patients is being studied. In one study OCD patients developed changes of mood within a few minutes, and depressed patients showed similar results. The mood benefits that one can receive from this treatment go away when the device is turned off or if the battery happens to die.

All of these treatments have the potential to benefit certain bipolar individuals although most of them are still in the process of being reviewed by the FDA.

For more information on bipolar treatments that are non-medicinal (but should be used in addition to medication) go to: http://www.moodswing.org/treatments.htm

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