INTERVENTIONAL PSYCHIATRY/COMPLEMENTARY APPROACHES
From New Frontiers in Depression Research and Treatment, presented by the University of California, San
Francisco, School of Medicine
| INTERVENTIONAL PSYCHIATRY: ECT, VNS, AND TMS —Stephen Hall, MD, Associate Clinical Professor
of Psychiatry and Director of Intensive Services, University of California, San Francisco, School of Medicine
|
| Electroconvulsive therapy (ECT)
|
 | Advantages: effective in >80% of people not yet treated for depression and in >50% of those with refractory
depression; rapid onset of action; resolves psychotic, melancholic, and suicidal symptoms quickly; no pharmacologic
complications; can be administered in combination with antidepressants or psychotherapy
|
| Disadvantages: requires general anesthesia, necessitating visit to hospital; can be stressful to cardiovascular system
(although safe in “vast majority” of patients); cognitive side effects; restrictions on activity (eg, work,
driving); high relapse rate; social stigma and fear
|
| Indications: unipolar or bipolar depression; depression secondary to medical illness; bipolar mania and rapid
cycling; acute episodes of disorders in schizophrenia spectrum
|
| Factors suggesting referral: rule of thumb, “the sicker or more impaired the patient, the more likely he or she
will respond to ECT”; patient’s physical deterioration or malnutrition; first-trimester pregnancy; catatonic,
melancholic, or psychotic features; manic delirium; history of response to ECT; patient preference; history
of treatment refractoriness; impracticality of pharmacotherapy (due to, eg, physical comorbidity, adverse
effects of medication, risk for overdose); need for rapid response (due to, eg, suicide risk, physical deterioration,
social circumstances)
|
| Factors associated with variable response: chronicity; dysthymia; mild symptomatology; relative absence of
neurovegetative signs; comorbid personality disorder; comorbid substance abuse
|
| Electrical parameters: newer machines have ability to deliver ultrabrief pulse, resulting in fewer cognitive
side effects
|
| Electrode placement: in general, bilateral ECT works better than unilateral; fewer treatments required with bilateral,
but cognitive side effects worse and more persistent
|
| Cognitive side effects: memory impairment includes transient anterograde and retrograde amnesia; rare reports
of spotty permanent memory loss; factors associated with greater impairment include bilateral treatment,
higher dose of electricity, and more frequent treatments; little evidence exists for other intellectual impairment
|
| Other considerations: ECT works especially well in elderly patients, refractory depression, and postpartum
disorders; patients with Parkinson’s disease may experience transient improvement of motor symptoms as
well as reduction in depression
|
| Vagal nerve stimulation (VNS)
|
| Brief history: VNS originally developed for treatment of medication-resistant epilepsy; >30 000 patients
worldwide have had implants for epilepsy; studies show many of these patients also experienced improvement
in mood, leading to exploration of VNS in treatment-resistant depression
|
| Device implantation: stimulator implanted in left chest wall, with electrode running subcutaneously to left
neck, where coils wrapped around vagus nerve; requires 2 incisions and short recovery period
|
| Contraindications: magnetic resonance imaging (MRI) of full body (MRI of head only fine); left cervical vagotomy;
“anything that causes metal to heat up” (eg, shortwave, microwave, diathermy)
|
| Adverse events: voice alteration most common; others include cough, shortness of breath, pain due to implantation
surgery; appears not to trigger mania
|
| Study results: modest in short-term (10-wk) study, but in 12-mo study, response rates increased over time and
patients who responded appeared to maintain response
|
| Other considerations: VNS compatible with medications and ECT; not for acute symptomatology; well tolerated
in studies; uncertain if insurance companies will pay for VNS for indication of depression
|
| Transcranial magnetic stimulation (TMS)
|
| Description: application of powerful localized variable magnetic field to scalp that induces localized electric
current in superficial brain cortex (2-3 cm); does not induce seizure if applied correctly
|
| Treatment variables: dose; pulse frequency; pulse train; intertrain interval; session duration; length of treatment
|
| Logistics: major cost is device itself; treatments can be done in office; noninvasive; no anesthesia needed; patient
awake and alert throughout treatment; patient sits or reclines in chair with headrest; patient and therapist
need ear protection; does not disrupt daily activities
|
| Side effects: tapping noise may affect high-frequency hearing; prickling sensation on scalp; transient headache;
8 seizures reported during initial studies, none since procedure refined; no significant cognitive or
cardiac problems occurred during studies
|
| Contraindications: personal or family history of epilepsy; presence of ferromagnetic implants (eg, pacemaker)
|
| Efficacy: early studies limited; shown to be better than placebo; in studies, efficacy equal to that of ECT in patients
with uncomplicated depression, below that of ECT in patients with psychotic depression; other trials under way
|
| Magnetic seizure therapy (MST): same technology as TMS but at higher frequency; requires general anesthesia
and operating-room setting; still in early development
|
| COMPLEMENTARY APPROACHES TO TREATMENT OF DEPRESSION —Sudha Prathikanti, MD, Associate
Clinical Professor of Psychiatry, University of California, San Francisco, School of Medicine
|
| Conventional treatments for depression: include antidepressant medications and variety of psychologic interventions;
remission rates relatively low (30%-45% with first course of treatment) and nonadherence rates
relatively high (30%-50%); patients often use unconventional approaches to replace or augment conventional
treatments
|
| Definitions: National Institutes of Health (NIH) define complementary and alternative medicine (CAM) as any
health care system, practice, or product currently not considered part of conventional medicine; “complementary”
means CAM used as adjunct to conventional treatment; “alternative” means CAM used in place of conventional
treatment
|
| Use of CAM by depressed patients: 13% to 22% in surveys that have formal criteria for assessing depression,
41% to 54% in surveys that do not (eg, survey may simply ask, “do you think you’re depressed?”); one
national survey found that people with depression used CAM remedies more often (54%) than conventional
care (36%)
|
| Types of CAM remedies for depression: mind-body therapies—include yoga, meditation, tai chi; “far and
away” most common; spiritual therapies—include prayer, religious or spiritual healing rituals; formerly lumped
with mind-body therapies, now considered separately; demographically “dichotomous” (ie, used by more
women than men, by more older people than younger, by more blacks and Latinos than whites and Asians);
biologically based therapies—include use of herbs, foods, vitamins, “anything supposed to have a bioactive
property associated with it”; least commonly used by patients, but have most research evidence because they
can be subjected to rigid scientific protocols; manual therapies—also called manipulative therapies; based on
movement of ≥1 body part; include massage, chiropractic; exercise—not considered CAM by NIH because
often recommended as part of conventional therapy, but included here because exercise not yet accepted as
viable alternative to antidepressants or psychotherapy
|
| Appeal of CAM therapies: they acknowledge interdependence of mind, body, and spirit; identification of
specific causal factor in illness less critical; practitioner activates patient’s capacity for self-healing; treatment
individualized; emphasis on preventing disease
|
| Limitations of CAM: quality of care usually unregulated; no monitoring of products used; efficacy often unverified
scientifically
|
| What is known about some specific CAM therapies
|
| Meditation: defined as self-regulation of attention; most often studied are concentration meditation (which includes
transcendental meditation and relaxation response) and mindfulness meditation (in which meditator
is compassionate witness to particular sensation or experience on which he or she wishes to focus); “literally
hundreds” of clinical studies done, mostly of concentration meditation, but few randomized controlled
trials; only 1 well-designed study, which considered mindfulness-based cognitive therapy as augmentation
to conventional treatment and studied only patients who had recovered from episode of depression (ie, they
were not depressed at time of their participation in study)
|
| Hatha yoga: most common form of yoga practiced in United States; uses combination of exercise postures
(asanas) and breathing techniques (pranayama); >75 studies done, but only 5 randomized controlled studies;
those 5 studies suggest positive effect of Hatha yoga, but number of subjects small and blinding done in
only 2 studies
|
| Acupuncture: traditionally involves insertion of needles into specific meridian points on body, followed by
electric or manual manipulation of needles; newer form uses heat from laser instead of needles; many studies
done, but lack of ideal placebo problematic; overall, studies suggest positive effect in treatment of depression
|
| Herbal remedies and supplements: St. John’s wort (Hypericum perforatum)—showed benefit in treating mild
to moderate depression in European studies, but not in US studies; NIH sponsoring ongoing study of St.
John’s wort in minor depression, results expected in next few years; warn patients about phototoxicity and
herb-drug interactions, especially with protease inhibitors, cyclosporine, warfarin, and digoxin; rhodiola
(Rhodiola rosea)—extensively tested in former Soviet Union, found to enhance mental performance under
stress in athletes and cosmonauts; only study of its effects on depression optimistic; valerian root (Valeriana
officinalis)—7 studies show effective in controlling insomnia and anxiety that often accompany depression;
optimum dose range 400 to 900 mg/day; metabolized in liver, so use with caution in patients with
liver disease; omega-3 fatty acids—small number of studies show omega-3 fatty acids from fish oil have
significant efficacy in bipolar and unipolar depression; educate patient to use preparation that has 2:1 ratio
of eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA); typical dose 2.5 g/day; folic acid—
worldwide, folate deficiency associated with increase in depression; speaker suggests that if woman not responding
well to tricyclic antidepressant (TCA) or selective serotonin reuptake inhibitor (SSRI), try augmentation
with folic acid (effect much weaker in men); S-adenosylmethionine (SAMe)—>80 clinical trials
in Europe show it may be comparable to TCAs in treatment of major depression, but doses must be 1400 to
1600 mg/day, “and it’s quite expensive”; has not yet been compared to SSRIs
|
| Exercise: meta-analysis of 14 randomized controlled trials showed exercise comparable to cognitive behavioral
therapy in treatment of depression, but all those trials had methodologic problems; more recent trial
tried to quantify amount of exercise needed to achieve antidepressant effect, found that intensity of exercise
matters; high caloric expenditure (17.5 cal/kg per week) necessary to achieve antidepressant effect, but
does not matter whether all expended in one exercise session or spread out over several sessions
|
Educational Objectives
| The goal of this program is to educate the listener about interventional techniques used in psychiatry and about complementary
approaches commonly utilized by patients. After hearing and assimilating this program, the clinician will
be better able to:
|
| 1. Provide a basic description of electroconvulsive therapy (ECT), vagal nerve stimulation (VNS), and transcranial
magnetic stimulation (TMS) to patients.
|
| 2. Refer to specialists patients who are appropriate candidates for ECT, VNS, and TMS.
|
| 3. Discuss the shortcomings of conventional treatment for depression that might encourage patients to seek complementary
and alternative medicine (CAM) therapies.
|
| 4. Describe some of the CAM therapies more commonly used by patients.
|
| 5. Summarize the scientific evidence, or lack thereof, supporting several CAM remedies.
|
Discussed on This Program
Folic acid (folacin; pteroylglutamic acid; folate) [Folvite]
Rhodiola (Rhodiola rosea)
S-adenosylmethionine (SAM-e)
St. John’s wort (Hypericum perforatum)
Valerian root (Valeriana officinalis)
Suggested Reading
Brown RP, Gerbarg PL: Herbs and nutrients in the treatment of depression, anxiety, insomnia, migraine, and obesity.
J Psychiatr Pract 7:75, 2001; Eitan R, Lerer B: Nonpharmacological, somatic treatments of depression: electroconvulsive
therapy and novel brain-stimulation modalities. Dialogues Clin Neurosci 8:241, 2006; Elger G et al:
Vagus nerve stimulation is associated with mood improvements in epilepsy patients. Epilepsy Res 42:203, 2000;
Geddes JR et al: Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review.
Lancet 361:653, 2003; George MS et al: A one-year comparison of vagus nerve stimulation with treatment as
usual for treatment-resistant depression. Biol Psychiatry 58:364, 2005; Keck PE Jr et al: Double-blind, randomized,
placebo-controlled trials of ethyl-eicosapentanoate in the treatment of bipolar depression and rapid cycling bipolar
disorder. Biol Psychiatry 2006 Jun 27; [Epub ahead of print]; Kelly GS: Rhodiola rosea: a possible plant
adaptogen. Altern Med Rev 6:293, 2001; Kosel M et al: Magnetic seizure therapy improves mood in refractory major
depression. Neuropsychopharmacology 28:2045, 2003; Leo RJ, Ligot JS Jr: A systematic review of randomized
controlled trials of acupuncture in the treatment of depression. J Affect Disord 2006 Aug 7; [Epub ahead of print];
Mathe AA: Neuropeptides and electroconvulsive treatment. J ECT 15:60, 1999; Muskiet FA, Kemperman RF:
Folate and long-chain polyunsaturated fatty acids in psychiatric disease. J Nutr Biochem 2006 Apr 28; [Epub ahead of
print]; O’Reardon JP et al: Long-term maintenance therapy for major depressive disorder with rTMS. J Clin Psychiatry
66:1524, 2005; Parker G et al: Omega-3 fatty acids and mood disorders. Am J Psychiatry 163:969, 2006;
Petrie RX, Reid IC, Stewart CA: The N-methyl-D-aspartate receptor, synaptic plasticity, and depressive disorder.
A critical review. Pharmacol Ther 87:11, 2000; Prudic J et al: Effectiveness of electroconvulsive therapy in
community settings. Biol Psychiatry 55:301, 2004; Prudic J, Sackeim HA: Electroconvulsive therapy and suicide
risk. J Clin Psychiatry 60(Suppl 2):104-, 2002; Quah-Smith JI, Tang WM, Russell J: Laser acupuncture for
mild to moderate depression in a primary care setting—a randomised controlled trial. Acupunct Med 23:103, 2005;
Randlov C et al: The efficacy of St. John’s Wort in patients with minor depressive symptoms or dysthymia—a
double-blind placebo-controlled study. Phytomedicine 13:215, 2006; Rush AJ et al: Effects of 12 months of vagus
nerve stimulation in treatment-resistant depression: a naturalistic study. Biol Psychiatry 58:355, 2005; Rush AJ et
al: Vagus nerve stimulation for treatment-resistant depression: a randomized, controlled acute phase trial. Biol Psychiatry
58:347, 2005; Sackeim HA et al: A prospective, randomized, double-blind comparison of bilateral and right
unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 57:425, 2000; Sackeim
HA et al: Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive
therapy. N Engl J Med 328:839, 1993; Sackeim HA et al: The impact of medication resistance and continuation
pharmacotherapy on relapse following response to electroconvulsive therapy in major depression. J Clin
Psychopharmacol 10:96, 1990; Scott BW, Wojtowicz JM, Burnham WM: Neurogenesis in the dentate gyrus
of the rat following electroconvulsive shock seizures. Exp Neurol 165:231, 2000; Trivedi MH et al: Exercise as an
augmentation strategy for treatment of major depression. J Psychiatr Pract 12:205, 2006; Trivedi MH et al:
TREAD: TReatment with Exercise Augmentation for Depression: study rationale and design. Clin Trials 3:291, 2006;
Weiss M, Nordlie JW, Siegel EP: Mindfulness-based stress reduction as an adjunct to outpatient psychotherapy.
Psychother Psychosom 74:108, 2005; Werneke U, Turner T, Priebe S: Complementary medicines in psychiatry:
review of effectiveness and safety. Br J Psychiatry 188:109, 2006; Williams JM et al: Mindfulness-based cognitive
therapy for prevention of recurrence of suicidal behavior. J Clin Psychol 62:201, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Hall and Prathikanti were recorded at New Frontiers in Depression Treatment and Research, held March 24-
26, 2006, in San Francisco, CA, and sponsored by the University of California, San Francisco, School of Medicine.
The Audio-Digest Foundation thanks the speakers and UCSF for their cooperation in the production of this program.
|
