The researchers concluded that electroconvulsive therapy, once known as "shock treatment," and antidepressant drugs are the most effective treatments for moderate to severe depression.
Psychiatry professor Klaus P. Ebmeier, MD, of the University of Edinburgh and colleagues reviewed developments in depression research within the last five years, focusing on recent advances and controversies.
They found that most patients improve with current treatments, although depression remains a widely undertreated condition.
The Drug Debate
A spate of recent news reports has questioned both the usefulness and safety of drug treatments for depression.
One of the most widely reported was the public spat between actor Tom Cruise and actress Brooke Shields last summer. Cruise publicly criticized Shields for taking selective serotonin reuptake inhibitor (SSRI) antidepressants to treat her postpartum depression after the birth of her first child.
Cruise called antidepressants "very dangerous" and claimed that there was no proof that chemical imbalances in the brain drive depression. Shields responded in a newspaper column, calling Cruise's assertions a "ridiculous rant."
Antidepressants and Suicide
Questions about whether SSRI use is associated with an increased risk of suicidal behavior in adults and children have also been much in the news.
Studies suggesting a link, especially in young people, prompted officials in the U.K. to conclude that antidepressants should not be used for the initial treatment of mild depression, and most SSRIs have been banned in Great Britain for use by children and teens.
In the U.S., the FDA ruled in 2004 that packaging for SSRI drugs must include a warning that patients taking them should be closely monitored for suicidal behavior.
Ebmeier and colleagues conclude that there is little unbiased scientific evidence to back up claims that the new-generation antidepressants are linked to suicides, adding that the moves by the regulatory agencies in the U.K. and U.S. are not justified.
"Recent moral panics about suicidal effects and dependence-inducing potential of antidepressants have tilted the balance of publicly perceived risk against them, but both their effectiveness and their ready availability make them the likely choice for most patients," they write.
Shock Therapy Revisited
The reviewers call electroconvulsive therapy (ECT) “the most effective treatment for depression, especially if patients present with psychotic symptoms, such as delusions and hallucinations.”
Max Fink, MD, who is widely known as “the grandfather of American ECT,” tells WebMD that studies continue to show that the treatment is highly effective in depressed patients with psychosis.
He says ECT was all but abandoned in the 1960s when antidepressant drugs became available, but they found a following once again in the 1980s as a treatment for severely depressed patients who did not respond to drugs.
According to the American Psychiatric Association, there is no evidence that ECT causes brain damage. Anesthesia and muscle relaxants are given during the procedure. Also, ECT cannot be administered without consent.
The most common side effects of ECT are headache, muscle soreness, and confusion shortly after the procedure. Patients may also experience some short-term memory loss, which usually improves over time (days to months).
The American Psychiatric Association says:
"Some people who advocate legislative bans against ECT are former psychiatric patients who have undergone the procedure and believe they have been harmed by it and that the treatment is used to punish patients' misbehavior and make them more docile. This is untrue. It is true that many years ago, when psychiatric knowledge was less advanced, ECT was used for a wide range of psychiatric problems, sometimes even to control troublesome patients. The procedure was frightening for patients because it was then administered without anesthesia or muscle relaxants, and the uncontrolled seizures sometimes broke bones."
Vagus Nerve Stimulation
An epilepsy treatment that was just approved for the treatment of depression works in a similar way to ECT, but its effects may last longer.
Like ECT, vagus nerve stimulation (VNS) uses electrical charges to relieve the symptoms of depression. But unlike the older treatment, the charges are delivered by a surgically implanted device that works much like a pacemaker.
The silver-dollar-sized device sends out pulses of electricity to the vagus nerve, which transmits them to the brain.
The reviewers noted that VNS has been proposed as a treatment in drug-resistant and ECT-resistant depressed patients, but they concluded that the "evidence for its effectiveness is as yet inconclusive."
They write that another experimental treatment, known as deep brain stimulation, has shown promise in several studies. Already in clinical use for the treatment of Parkinson's disease, deep brain stimulation involves the surgical implantation of electrodes in specific regions of the brain.
"Of the physical treatments only ECT is in regular clinical use," Ebmeier and colleagues wrote. The newer therapies "offer hope of treatment that is potentially less invasive or less liable to generate memory impairment."