Magazine article Clinical Psychiatry News

Depression Tx: New Tools Abound. (Transcranial Magnetic Stimulation)

Magazine article Clinical Psychiatry News

Depression Tx: New Tools Abound. (Transcranial Magnetic Stimulation)

Article excerpt

SAN FRANCISCO -- A mind-numbing slew of acronyms represent a recent boom in brain-stimulating technologies to treat psychiatric and neurologic disorders. Besides the old standby ECT, there's now MST, TMS, VNS, and DBS.

The newer modalities may be able to treat severe depression with fewer side effects compared with electroconvulsive therapy (ECT), but none are approved for that purpose yet.

But two of the techniques are approved for other indications: vagal nerve stimulation (VNS), for the treatment of epilepsy, and deep brain stimulation (DBS), to treat symptoms of Parkinson's disease. Both are being studied for the treatment of depression, and DBS has shown some efficacy in an uncontrolled pilot study of patients with treatment-resistant obsessive-compulsive disorder.

The other two investigational techniques--magnetic seizure therapy (MST) and transcranial magnetic stimulation (TMS)-- are noninvasive and produce fewer side effects than ECT. In addition, TMS does not require anesthesia and does not induce seizures. (See box.)

For those reasons, TMS may be the most promising of the brain stimulation strategies so far, if it is proven to be effective, according to experts who spoke in separate symposia at the annual meeting of the American Psychiatric Association.

The new tools are likely to "drastically change neuropsychiatry research and depression treatment," said Dr. Mark S. George, director of the Brain Stimulation Laboratory and the Center for Advanced Imaging Research at the Medical University of South Carolina, Charleston.

He has two patents pending for combinations of brain stimulation and brain imaging technologies. Dr. George has received funding from or is on the speakers' bureau of several companies that make brain stimulation devices, including Dantec, Cadwell Laboratories Inc., Medtronic Inc., Neotonus Inc., Cyberonics Inc., and MagStim Co.

"I remain convinced that in 20 years none of these [current modalities] will be used; these will be bridging technologies to a future of less invasive technologies I can't see yet," added Dr. George, who is also professor of psychiatry, radiology, and neurology at the university.

In the meantime, ECT remains the most effective therapy available for major depression, Dr. Sarah H. Lisanby said in a separate presentation. She and Dr. George provided an overview of ECT and the investigational alternatives:

* ECT. Old enough that it predates the Food and Drug Administration, ECT was grand-fathered into approval for the treatment of depression, mania, and catatonia. A spatially crude technique that cannot target specific brain areas and causes significant side effects, ECT nevertheless maintains an important role in treating patients who fail to respond to initial psychopharmacology, who cannot tolerate other treatments, or who require rapid improvement. "It's a life-saver," Dr. George said.

An ECT-induced seizure is required but not sufficient to produce clinical improvement, data in recent decades have shown. No one yet knows how ECT treats depression--or why it works--but it has become clear over time that brief pulse widths produce results with fewer cognitive side effects, such as amnesia.

The American Psychiatric Association no longer recommends the use of longerpulse sine wave ECT devices, but they are still in use in some places, noted Dr. Lisanby, president of the Association for Convulsive Therapy Four depressed patients would need to receive ECT to have statistical confidence that one patient improved as a result of the treatment, sham-controlled studies have shown. In psychiatry, a "number needed to treat" of less than 10 is considered -indicative of a worthwhile treatment, said Dr. Lisanby, of Columbia University and the New York State Psychiatric Institute, New York.

ECT also has been used in schizophrenia. Eight studies that compared ECT with sham treatment for schizophrenia in a combined 380 patients found that 7 patients would need to be treated with ECT to produce superior results, compared with placebo. …

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