When medication fails to ease the symptoms of clinical depression, there are other options to try. Brain stimulation techniques such as electroconvulsive therapy (ECT), for example, can be used to treat major depression that hasn't responded to standard treatments.
The least invasive of these techniques is called transcranial magnetic stimulation (TMS), in which a magnetic field is created by a device held above the head, causing a weak electrical signal to be applied to the prefrontal cortex, the region of the brain that is connected to mood.
Vagus nerve stimulation (VNS) is another treatment for depression that uses a surgically implanted pacemaker-like device that electrically stimulates a nerve that runs up the neck into the brain. The nerve is called the vagus nerve. With ECT, an electric current is briefly applied through the scalp to the brain, inducing a seizure.
In addition, alternative therapies such as yoga and hypnosis sometimes work for mild depression.
What Is Electroconvulsive Therapy (ECT)?
ECT is among the safest and most effective treatments available for depression. With ECT, electrodes are placed on the patient's scalp and a finely controlled electric current is applied while the patient is under general anesthesia. The current causes a brief seizure in the brain. ECT is one of the fastest ways to relieve symptoms in severely depressed or suicidal patients. It's also very effective for patients who have mania or a number of other mental illnesses.
ECT is generally used when severe depression doesn’t respond to other forms of therapy. Or it might be used when patients pose a severe threat to themselves or others and it is too dangerous to wait until medications take effect.
Although ECT has been used since the 1940s and 1950s, it remains misunderstood by the general public. Many of the procedure's risks and side effects are related to the misuse of equipment, incorrect administration, or improperly trained staff. It is also a misconception that ECT is used as a "quick fix" in place of long-term therapy or hospitalization. Nor is it correct to believe that the patient is painfully "shocked" out of the depression. Unfavorable news reports and media coverage have contributed to the controversy surrounding this treatment.
How Is ECT Performed?
Prior to ECT treatment, a patient is given a muscle relaxant and is put to sleep with a general anesthesia. Electrodes are placed on the patient's scalp and a finely controlled electric current is applied. This current causes a brief seizure in the brain.
Because the muscles are relaxed, the visible effects of the seizure will usually be limited to slight movement of the hands and feet. Patients are carefully monitored during the treatment. The patient awakens minutes later, does not remember the treatment or events surrounding it, and is often confused. The confusion typically lasts for only a short period of time.
ECT is usually given up to three times a week for a total of 2 to 4 weeks.
How Electroconvulsive Therapy Works
With ECT, an electrical stimulation is delivered to the brain and causes a seizure. For reasons that doctors don't completely understand, this seizure helps relieve the symptoms of depression. ECT does not cause any structural damage to the brain.
The procedure itself typically requires a stay in the hospital.
The number of required sessions varies. Many people have six to 12 sessions given two to three times per week over a period of several weeks. After the first treatment, you might require further ECT treatments in addition to depression medicine and therapy to prevent your depression from returning.
Studies have shown that ECT works for many people who have treatment-resistant depression. One study of 39 people with treatment-resistant depression compared the effects of an antidepressant with ECT. After 2 to 3 weeks, 71% of people who received ECT had a positive response to treatment. But only 28% who received the antidepressant had a positive response after 4 weeks of treatment. The results were published in 1997 in the medical journal Acta Psychiatrica Scandinavia.
Who Might Benefit From ECT?
According to the American Psychiatric Association, ECT can be beneficial and safe in the following situations:
- When a need exists for rapid treatment response, such as in pregnancy
- When a patient refuses food and that leads to nutritional deficiencies
- When a patient's depression is resistant to antidepressant therapy
- When other medical ailments prevent the use of antidepressant medication
- When the patient is in a catatonic stupor
- When the depression is accompanied by psychotic features
- When treating bipolar disorder, including both mania and depression
- When treating mania
- When treating patients who have a severe risk of suicide
- When treating patients who have had a previous response to ECT
- When treating patients with psychotic depression or psychotic mania
- When treating patients with major depression
Risks and Side Effects of ECT
The most common side effect of ECT is short-term memory loss. However, some people report that they have long-term memory loss, as well. ECT also causes a brief rise in heart rate and blood pressure during the procedure, so it may not be recommended in people with unstable heart problems. A physical examination and basic laboratory tests, including an electrocardiogram (EKG), are necessary before starting ECT to assure that no medical problems are present that could interfere with the safe administration of ECT.
ECT can often work quickly, but 50% or more of the people who receive this treatment will relapse within several months if there is no subsequent treatment (for example, medicines) to prevent relapse. Your doctor will typically advise a medication plan including antidepressants, or possibly additional periodic ("maintenance") ECT sessions to help prevent relapse.
Life After ECT
After ECT, patients may have temporary side effects such as confusion, disorientation, and memory loss. These side effects usually improve within a few days to a few weeks. Some patients may also have headaches, muscle aches, and nausea. Patients will be required to follow safety precautions such as avoiding driving or operating heavy machinery until cleared by the health care provider and avoiding alcohol and medications that can interact with the anesthesia used during the procedure. It is important to have realistic expectations about recovery time and outcome, as the recovery process will be different for each person.
What Is Transcranial Magnetic Stimulation (TMS)?
While ECT uses an electric current to induce seizure, TMS creates a magnetic field to induce a much smaller electric current in a specific part of the brain without causing seizure or loss of consciousness. The current is caused by the magnetic field created by an electromagnetic coil that delivers the pulses through the forehead.
Approved by the FDA in 2008 for treatment-resistant depression, TMS works best in patients who have failed to benefit from one, but not two or more, antidepressant treatments. Also, unlike ECT, TMS does not require sedation and is administered on an outpatient basis. Patients having TMS must be treated four or five times a week for 4 to 6 weeks.
Research has shown that TMS produces few side effects and is both safe and effective for medication-resistant depression. But its effectiveness as currently performed appears to be less than that of ECT.
What Is Vagus Nerve Stimulation (VNS)?
A vagus nerve stimulator (VNS) device was approved by the FDA for adult patients with long-term or recurrent major depression. Some patients who undergo VNS may have been taking many medications for depression yet continue to suffer with its symptoms.
How VNS works: The small stimulator is implanted under the skin of the collarbone and runs under the skin to the vagus nerve in the neck. The device emits electrical pulses to stimulate the brain.
What Alternative Treatments Are Used for Depression?
Alternative treatments can sometimes provide relief that traditional Western medicine cannot. While some alternative therapies have become accepted as part of modern health care practice, others still have not been proven safe or effective.
Whether or not they are scientifically proven, alternative therapies, by providing forms of relaxation and relief from stress, may have a place in healing and general health and well-being. Examples of alternative therapies include acupuncture, guided imagery, chiropractic treatments, yoga, hypnosis, biofeedback, aromatherapy, relaxation, herbal remedies, and massage.
In general, alternative therapies by themselves are reasonable to use for mild but not more severe forms of clinical depression.
Are There any Experimental Depression Therapies Being Tested?
Experimental therapies are treatments that are not regularly used by doctors. Their safety and effectiveness are still being studied.
Some experimental therapies currently being investigated for treatment of depression include:
- Hormone replacement therapy (HRT) in women: Depression is more common in women than in men. Changes in mood with premenstrual syndrome(PMS) and premenstrual dysphoric disorder (PMDD), post-childbirth, and postmenopause are all linked with sudden drops in hormone levels. Hormone replacement is a treatment currently used to relieve symptoms of menopause such as night sweats and hot flashes. HRT can also help prevent bone-thinning osteoporosis. But the true contribution of hormones to depression is not known. Be sure to tell your doctor if you have had depression before and are considering HRT.
- Intravenous or internasal ketamine: The anesthetic agent ketamine has been approved for treatment of severe depression. It has been shown in preliminary studies to produce a rapid (within hours) improvement in depression for and is recognized as effective in some patients.
- Riluzole: (Relutek, Tiglutik): This medicine, originally used to treat motor neuron disorders such as amyotrophic lateral sclerosis (ALS, or Lou Gehrig's Disease), has been shown also to affect neurotransmitters involved in depression, and in early studies has begun to show promise in treating depression that is unresponsive to more traditional medicines.
Can Depression Return if You Stop Treatment?
Even when treatment such as ECT, TMS, vagus nerve stimulation, or other alternative therapies is successful, depression can return. Psychotherapy and/or maintenance antidepressant medication can help prevent depression from coming back. Psychotherapy does this by correcting the beliefs, perceptions, and behaviors that contribute to your depression. If you do have recurring symptoms, don't hesitate to seek help again.
What Is the Outlook for Depression?
The outlook for depressed people who seek treatment is very promising. By working with a qualified and experienced mental health care professional, you can regain control of your life.