Electroconvulsive Therapy, Transcranial Magnetic Stimulation, and Deep Brain Stimulation in Treatment-Resistant Depression

Abstract

Treatment-resistant depression (TRD) continues to challenge current therapeutic options, especially pharmacologic treatments often used as first-line management. Thus, multimodality treatments, including neurostimulation techniques, are sought for symptom improvement. Since the first use of electroconvulsive therapy (ECT), the field of neurostimulation has strived to find treatments that improve safety, efficacy, and the side-effect profile to provide relief for patients suffering from TRD. Development in neurostimulation is spurred by ongoing innovation in technology, but also by increasing awareness that TRD frequently requires multimodal approaches for optimal symptom relief. This article reviews the most recent advances in ECT, transcranial magnetic stimulation (TMS), and deep brain stimulation (DBS) for use in TRD. ECT, TMS, and DBS are all researched in the treatment of depression, with ECT and TMS having approval from the US Food and Drug Administration, but differ widely in techniques, protocols, and patient selection parameters. ECT has the most data backing efficacy, but needs ancillary support (anesthesia, support staff) for implementation, and considerable stigma still represents an obstacle to widespread use. TMS and DBS, although less efficacious than ECT, are gaining popularity and as additional knowledge is acquired in regards to ideal use, circumstances may allow for them to become mainstream treatments for TRD in the next decade. [ Psychiatr Ann . 2016;46(4):240–246.]

Treatment‐resistant depression: An overview for psychiatric advanced practice nurses

“…37 The neuroendocrine theory hypothesizes that ECT induces activation of the hypothalamicpituitary axis and subsequent hormone release, and these hormones mediate antidepressant effects. 38 Regarding the anticonvulsant theory, it is hypothesized that GABA mediates antidepressant effects of ECT that arise as seizure threshold increases. 39 Finally, the neurotrophic theory suggests that ECT precipitates neurogenesis and increases in synaptic signaling by increased neurotrophic factors, including brainderived neurotrophic factor.…”

Depression Remission and Response Rates and Anxiety Response as a Predictor of Depression Response in a Community ECT Clinic

“…[4][5][6] Fewer hospitals, particularly those treating largely publicly insured patients, conduct ECT, which has contributed to a decreased utilization of ECT. 7 Due to a number of additional factors negatively associated with ECT use, including stigma, financial constraints, insurance barriers, legal and political policies, cognitive side effects, and transportation, 8,9 ECT is often reserved for patients who have failed multiple medication trials (patients with treatment resistant depression). 10,11 Treatment resistant depression is associated with poorer quality of life, increased mortality and poor clinical outcomes.…”